1 00:00:05,765 --> 00:00:07,834 TODAY I THINK WE HAVE A TOPIC 2 00:00:07,834 --> 00:00:09,970 WE ALL ARE INTERESTED IN, IN 3 00:00:09,970 --> 00:00:12,739 TERMS OF SURGE CAPACITY. 4 00:00:12,739 --> 00:00:16,843 DURING COVID, ALL OF US 5 00:00:16,843 --> 00:00:17,644 REALIZED HOSPITALS WERE 6 00:00:17,644 --> 00:00:19,179 INUNDATED WITH PATIENTS. 7 00:00:19,179 --> 00:00:23,683 THEY DIDN'T HAVE ENOUGH PATIENT 8 00:00:23,683 --> 00:00:26,019 BEDS SO THEY USED ALL KIND OF 9 00:00:26,019 --> 00:00:28,121 HEALTHCARE WORKERS TO WORK IN 10 00:00:28,121 --> 00:00:28,722 SITUATIONS THEY WEREN'T 11 00:00:28,722 --> 00:00:29,990 NECESSARILY EXPERIENCED IN. 12 00:00:29,990 --> 00:00:31,391 THE QUESTION IS WHAT DID THAT 13 00:00:31,391 --> 00:00:33,026 DO TO THE QUALITY OF CARE OR 14 00:00:33,026 --> 00:00:34,961 OUTCOMES? 15 00:00:34,961 --> 00:00:38,365 TONIGHT WE ARE FORTUNATE TO 16 00:00:38,365 --> 00:00:38,965 TALK ABOUT "SAVING LIVES WHEN 17 00:00:38,965 --> 00:00:39,599 HOSPITALS ARE SURGING & FUTURE 18 00:00:39,599 --> 00:00:40,200 IMPLICATIONS OF SURGE STRAIN: 19 00:00:40,200 --> 00:00:40,734 LESSONS FROM THE COVID-19 20 00:00:40,734 --> 00:00:42,369 PANDEMIC." 21 00:00:42,369 --> 00:00:44,537 WE HAVE TWO PEOPLE WITH 22 00:00:44,537 --> 00:00:48,274 SLIGHTLY DIFFERENT PERSPECTIVES. 23 00:00:48,274 --> 00:00:50,910 ONE IS SAMEER KADRI, A MEMBER 24 00:00:50,910 --> 00:00:52,912 OF THE CRITICAL MEDICINE 25 00:00:52,912 --> 00:00:55,081 DEPARTMENT IN NIH. 26 00:00:55,081 --> 00:00:56,282 TRAINED IN CRITICAL MEDICINE, 27 00:00:56,282 --> 00:00:58,251 WENT TO HARVARD FOR INFECTIOUS 28 00:00:58,251 --> 00:01:01,254 DISEASE TRAINING. 29 00:01:01,254 --> 00:01:01,955 INTRODUCED TO POPULATION 30 00:01:01,955 --> 00:01:03,823 MEDICINE AND HE CAME BACK HERE 31 00:01:03,823 --> 00:01:05,992 TO START A PROGRAM IN 32 00:01:05,992 --> 00:01:06,893 HEALTHCARE SERVICES RESEARCH. 33 00:01:06,893 --> 00:01:09,496 HE HAS BEEN VERY SUCCESSFUL 34 00:01:09,496 --> 00:01:10,397 WORKING WITH PROFESSIONAL 35 00:01:10,397 --> 00:01:12,565 STUDIES, WORKING WITH THE CDC 36 00:01:12,565 --> 00:01:13,466 AND THE FDA. 37 00:01:13,466 --> 00:01:16,002 HE WILL BE TALKING ABOUT THIS 38 00:01:16,002 --> 00:01:17,203 FROM HIS PERSPECTIVE. 39 00:01:17,203 --> 00:01:20,473 WE ALSO HAVE WITH US, JOHN 40 00:01:20,473 --> 00:01:23,510 HICKS, WHO HAS HAD A VERY 41 00:01:23,510 --> 00:01:24,678 SUCCESSFUL CAREER IN MINNESOTA, 42 00:01:24,678 --> 00:01:28,782 BECOMING A NATIONAL LEADER IN 43 00:01:28,782 --> 00:01:30,316 DISASTER PLANNING AND IN 44 00:01:30,316 --> 00:01:31,351 EMERGENCY PREPAREDNESS. 45 00:01:31,351 --> 00:01:35,622 HE HAS BEEN THE CHIEF OF 46 00:01:35,622 --> 00:01:37,257 EMERGENCY PREPAREDNESS FOR 47 00:01:37,257 --> 00:01:39,592 HAMPTON COUNTY HEALTH AND 48 00:01:39,592 --> 00:01:42,429 HEALTHCARE SERVICES AND BECAUSE 49 00:01:42,429 --> 00:01:45,498 OF HIS EXPERTISE HE IS WORKING 50 00:01:45,498 --> 00:01:47,100 PART-TIME FOR HHS ASSISTANT 51 00:01:47,100 --> 00:01:48,702 SECRETARY FOR PREPAREDNESS SO 52 00:01:48,702 --> 00:01:50,270 HE SPLITS HIS TIME BETWEEN 53 00:01:50,270 --> 00:01:51,771 MINNESOTA AND HERE. 54 00:01:51,771 --> 00:01:53,339 I'M PLEASED TO HAVE THESE TWO 55 00:01:53,339 --> 00:01:54,340 SPEAKERS HERE. 56 00:01:54,340 --> 00:01:58,278 SOSA MERE? 57 00:01:58,278 --> 00:02:01,047 -- SO, SAMEER? 58 00:02:01,047 --> 00:02:03,450 >> Sameer Kadri: THANK YOU VERY 59 00:02:03,450 --> 00:02:08,154 MUCH, DR. MASUR FOR THE KIND 60 00:02:08,154 --> 00:02:13,460 INTRODUCTION AND DR. MERKLO FOR 61 00:02:13,460 --> 00:02:14,694 THE OPPORTUNITY TO PRESENT 62 00:02:14,694 --> 00:02:16,563 RESEARCH ON THE PERILS OF OVER 63 00:02:16,563 --> 00:02:17,997 CROWDING DURING THE PANDEMIC. 64 00:02:17,997 --> 00:02:20,066 OVER THE NEXT 20 MINUTES OR SO, 65 00:02:20,066 --> 00:02:23,269 I WANT TO WALK YOU THROUGH SOME 66 00:02:23,269 --> 00:02:26,573 KEY INSIGHT FROM TEN BIG DATA 67 00:02:26,573 --> 00:02:27,340 INVESTIGATIONS WE CARRIED OUT 68 00:02:27,340 --> 00:02:28,441 DURING THE PANDEMIC. 69 00:02:28,441 --> 00:02:33,913 I HAVE NO FINANCIAL DISCLOSURES. 70 00:02:33,913 --> 00:02:36,049 MANY OF US WANT TO FORGET ABOUT 71 00:02:36,049 --> 00:02:38,184 THE HORRIBLE FIRST TWO YEARS OF 72 00:02:38,184 --> 00:02:40,253 THE PANDEMIC AS A BAD DREAM. 73 00:02:40,253 --> 00:02:42,122 BUT AS PEOPLE OF SCIENCE WE 74 00:02:42,122 --> 00:02:44,257 WOULD BE DOING A DISSERVICE TO 75 00:02:44,257 --> 00:02:45,658 THE 27 MILLION PEOPLE WHO LOST 76 00:02:45,658 --> 00:02:48,661 THEIR LIVES IN THE PANDEMIC, 77 00:02:48,661 --> 00:02:51,431 WHOSE DEATHS ARE LABELED AS 78 00:02:51,431 --> 00:02:52,665 EXCESS DEATHS. 79 00:02:52,665 --> 00:02:55,268 DEFINED AS THE NUMBER OF DEATHS 80 00:02:55,268 --> 00:02:57,637 IN A GIVEN COUNTRY DURING THE 81 00:02:57,637 --> 00:02:59,773 PANDEMIC, MINUS THE AVERAGE 82 00:02:59,773 --> 00:03:00,640 PRE-PANDEMIC DEATH RATE FOR 83 00:03:00,640 --> 00:03:03,343 THAT COUNTRY. 84 00:03:03,343 --> 00:03:05,445 AND THE ECONOMISTS SHOWED US 85 00:03:05,445 --> 00:03:07,747 THAT ONLY A SMALL FRACTION OF 86 00:03:07,747 --> 00:03:10,316 EVERYONE WHO DIED AND WHO HAD 87 00:03:10,316 --> 00:03:11,084 EXCESS DEATHS ACTUALLY HAD 88 00:03:11,084 --> 00:03:12,185 COVID. 89 00:03:12,185 --> 00:03:14,254 THAT MEANS THERE'S A LOT OF 90 00:03:14,254 --> 00:03:18,525 PEOPLE WHO ARE BY STANDERS IN A 91 00:03:18,525 --> 00:03:20,927 HEALTH SYSTEM AND HEALTHCARE 92 00:03:20,927 --> 00:03:23,029 SETTINGS WRECKED BY THE 93 00:03:23,029 --> 00:03:23,763 PANDEMIC, HEART ATTACKS, 94 00:03:23,763 --> 00:03:25,265 STROKES, ET CETERA, THAT DIED 95 00:03:25,265 --> 00:03:26,766 BECAUSE OF THE PERILS OF OVER 96 00:03:26,766 --> 00:03:30,069 CROWDING, WE THINK. 97 00:03:30,069 --> 00:03:32,405 UNFORTUNATELY, THE U.S. RANKS 98 00:03:32,405 --> 00:03:34,941 AMONGST ONE OF THE HIGHEST IN 99 00:03:34,941 --> 00:03:35,608 EXCESS MORTALITY RATE DURING 100 00:03:35,608 --> 00:03:37,510 THE PANDEMIC. 101 00:03:37,510 --> 00:03:39,412 WHICH BEHOOVES US TO TAKE A 102 00:03:39,412 --> 00:03:42,549 CLOSER LOOK WITH A MAGNIFYING 103 00:03:42,549 --> 00:03:44,384 GLASS TO FIGURE OUT WHAT WE DID 104 00:03:44,384 --> 00:03:45,685 WRONG AND WHAT WE CAN DO BETTER 105 00:03:45,685 --> 00:03:46,986 IN THE FUTURE. 106 00:03:46,986 --> 00:03:49,088 MANY OF YOU ARE AWARE HOSPITALS 107 00:03:49,088 --> 00:03:51,925 WERE BURSTING AT THE SEAMS AT 108 00:03:51,925 --> 00:03:52,458 SEVERAL POINTS DURING THE 109 00:03:52,458 --> 00:03:54,060 PANDEMIC. 110 00:03:54,060 --> 00:03:55,495 I REMEMBER BEING IN SOME OF 111 00:03:55,495 --> 00:03:57,063 THESE SURGING HOSPITALS IN THE 112 00:03:57,063 --> 00:03:58,965 COMMUNITY EARLY ON IN THE 113 00:03:58,965 --> 00:04:00,600 PANDEMIC, AND I COULDN'T HELP 114 00:04:00,600 --> 00:04:04,170 BUT NOTICE A LOT OF CRITICAL 115 00:04:04,170 --> 00:04:06,072 ELEMENTS OF CLINICAL MANAGEMENT 116 00:04:06,072 --> 00:04:07,473 WERE SLIPPING THROUGH THE 117 00:04:07,473 --> 00:04:07,941 CRACKS. 118 00:04:07,941 --> 00:04:11,044 THERE WERE JUST NOT ENOUGH 119 00:04:11,044 --> 00:04:12,245 HANDS, ENOUGH EYES, ENOUGH 120 00:04:12,245 --> 00:04:14,781 BRAINS TO PROVIDE THE 121 00:04:14,781 --> 00:04:15,748 HIGH-PRECISION CARE WARRANTED 122 00:04:15,748 --> 00:04:17,851 FOR PATIENTS WHO ARE CRITICALLY 123 00:04:17,851 --> 00:04:19,085 ILL, WITH COVID-19 AND OTHER 124 00:04:19,085 --> 00:04:23,690 PROBLEMS. 125 00:04:23,690 --> 00:04:28,261 IT RAISED THE QUESTION IN MY 126 00:04:28,261 --> 00:04:30,330 MIND DID HOSPITAL EXCESS STRAIN 127 00:04:30,330 --> 00:04:31,764 DRIVE SOME OF THESE EXCESS 128 00:04:31,764 --> 00:04:33,967 DEATHS. 129 00:04:33,967 --> 00:04:39,472 FLAG REPRESENTS EXCESS DEATH 130 00:04:39,472 --> 00:04:39,906 DURING THE PANDEMIC. 131 00:04:39,906 --> 00:04:40,907 OUR HYPOTHESIS FRAMEWORK WE 132 00:04:40,907 --> 00:04:42,775 BUILT WAS THAT OVER CROWDED 133 00:04:42,775 --> 00:04:44,177 HOSPITALS LIKELY LEAD TO PEOPLE 134 00:04:44,177 --> 00:04:46,379 NOT COMING TO THE HOSPITAL AND 135 00:04:46,379 --> 00:04:48,147 DYING AT HOME. 136 00:04:48,147 --> 00:04:50,283 WHEN WE HAVE EXCELLENT BACK 137 00:04:50,283 --> 00:04:56,789 SCENES THAT CAME ABOUT -- 138 00:04:56,789 --> 00:04:58,424 VACCINES THAT CAME ABOUT AND 139 00:04:58,424 --> 00:05:00,727 PEOPLE DECIDED NOT TO TAKE IT, 140 00:05:00,727 --> 00:05:03,396 IT LED TO MORE PEOPLE COMING TO 141 00:05:03,396 --> 00:05:04,264 THE HOSPITAL AND OCCUPYING 142 00:05:04,264 --> 00:05:05,732 RESOURCES. 143 00:05:05,732 --> 00:05:08,568 WE HAVE FOUR MEDIATORS WE THINK 144 00:05:08,568 --> 00:05:09,969 MEDIATED THE POOR OUTCOME 145 00:05:09,969 --> 00:05:10,470 RELATED TO OVER CROWDED 146 00:05:10,470 --> 00:05:12,038 HOSPITALS. 147 00:05:12,038 --> 00:05:14,974 ONE WAS CRITICAL SHORTAGES. 148 00:05:14,974 --> 00:05:16,643 THIS IS THE DEMAND/SUPPLY 149 00:05:16,643 --> 00:05:18,778 IMBALANCE BETWEEN TOO MANY 150 00:05:18,778 --> 00:05:20,847 PATIENTS, TOO FEW BEDS, 151 00:05:20,847 --> 00:05:22,715 EQUIPMENT, TOO FEW PERSONNEL, 152 00:05:22,715 --> 00:05:28,955 EYES, HANDS, BRAINS. 153 00:05:28,955 --> 00:05:36,362 WE MADE A LOT OF IMPLICIT 154 00:05:36,362 --> 00:05:37,497 TRIAGE DECISIONS, THAT PROBABLY 155 00:05:37,497 --> 00:05:39,198 ALSO PLAYED A ROLE. 156 00:05:39,198 --> 00:05:41,100 WE WERE UNABLE TO TRANSFER 157 00:05:41,100 --> 00:05:42,936 PATIENTS WHO REQUIRED VITAL 158 00:05:42,936 --> 00:05:44,070 SERVICES AT OTHER HOSPITALS 159 00:05:44,070 --> 00:05:45,838 THEY COULD NOT GET AT THEIR 160 00:05:45,838 --> 00:05:47,073 PARENT HOSPITAL. 161 00:05:47,073 --> 00:05:48,274 THAT PROBABLY PLAYED A ROLE. 162 00:05:48,274 --> 00:05:50,143 AND WE HAD TO ALTER OUR CARE 163 00:05:50,143 --> 00:06:00,320 STANDARDS. 164 00:06:00,787 --> 00:06:04,724 THIS IS CALLED CRISIS CARE. 165 00:06:04,724 --> 00:06:08,428 YOU WILL HEAR ABOUT IT MORE 166 00:06:08,428 --> 00:06:10,663 DURING DR. HICKS TALK. 167 00:06:10,663 --> 00:06:12,899 EARLY TRIGGER FOR COMFORT CARE, 168 00:06:12,899 --> 00:06:16,002 PRACTICING OUTSIDE SCOPE AND 169 00:06:16,002 --> 00:06:16,569 LIMITING RESOURCE-INTENSIVE 170 00:06:16,569 --> 00:06:18,304 CARE. 171 00:06:18,304 --> 00:06:21,074 I WAS FORTUNATE I AM IN THE 172 00:06:21,074 --> 00:06:24,811 INTERMURAL COMMUNITY AND WE HAD 173 00:06:24,811 --> 00:06:25,745 A PRE-EXISTING RELATIONSHIP 174 00:06:25,745 --> 00:06:28,147 WITH SOME OF THE FEDERAL 175 00:06:28,147 --> 00:06:31,484 AGENCIES WE DID WORK WITH 176 00:06:31,484 --> 00:06:36,889 SEPSIS, WE LIMITED THIS TO DO 177 00:06:36,889 --> 00:06:37,724 OUR INVESTIGATIONS AT WARP 178 00:06:37,724 --> 00:06:39,425 SPEED. 179 00:06:39,425 --> 00:06:41,995 THE CDC CAME TO US WITH BURNING 180 00:06:41,995 --> 00:06:43,396 QUESTIONS THEY WERE UNABLE TO 181 00:06:43,396 --> 00:06:45,398 ANSWER THAT HAD A CLINICAL TILT 182 00:06:45,398 --> 00:06:47,633 THAT WE WERE ABLE TO ANSWER. 183 00:06:47,633 --> 00:06:49,969 AND WE LEVERAGED THE CDC TO 184 00:06:49,969 --> 00:06:51,404 BETTER MESSAGE AND COMMUNICATE 185 00:06:51,404 --> 00:06:53,706 OUR FINDINGS TO THE PUBLIC. 186 00:06:53,706 --> 00:06:54,907 WE HAD A PREEXISTING FRAMEWORK 187 00:06:54,907 --> 00:06:57,010 OF HOW TO DO THIS RESEARCH 188 00:06:57,010 --> 00:06:58,678 BASED ON OUR TRACK RECORD OF 189 00:06:58,678 --> 00:07:01,481 BIG DATA INVESTIGATIONS IN THE 190 00:07:01,481 --> 00:07:02,548 FIELD OF ANTIBIOTIC RESISTANCE 191 00:07:02,548 --> 00:07:03,850 AND SEPSIS. 192 00:07:03,850 --> 00:07:06,185 AND WE USED PRIMARILY A LARGE 193 00:07:06,185 --> 00:07:07,987 DATABASE CALLED THE PREMIERE 194 00:07:07,987 --> 00:07:11,357 HEALTHCARE DATABASE. 195 00:07:11,357 --> 00:07:12,959 THIS COMPANY RELEASED SOMETHING 196 00:07:12,959 --> 00:07:14,560 SPECIAL COVID-19 RELEASE. 197 00:07:14,560 --> 00:07:16,562 SO THEY ESSENTIALLY GAVE US 198 00:07:16,562 --> 00:07:18,164 DATA EVERY 15 DAYS. 199 00:07:18,164 --> 00:07:20,266 THE DATA WAS AS RECENT AS THREE 200 00:07:20,266 --> 00:07:21,868 WEEKS AGO. 201 00:07:21,868 --> 00:07:26,973 THESE DATA COME FROM 900 U.S. 202 00:07:26,973 --> 00:07:30,243 HOSPITALS AND COMBINATION OF 203 00:07:30,243 --> 00:07:32,145 ADMINISTRATIVE BUT ALSO 204 00:07:32,145 --> 00:07:33,212 CLINICAL DATA, LAB VALUES, 205 00:07:33,212 --> 00:07:34,947 VITALS ET CETERA. 206 00:07:34,947 --> 00:07:37,517 THESE DATA WERE VERY HELPFUL IN 207 00:07:37,517 --> 00:07:39,552 BEING ABLE TO ANSWER QUESTIONS 208 00:07:39,552 --> 00:07:40,286 USING PANDEMIC DATA IN THE 209 00:07:40,286 --> 00:07:42,722 PANDEMIC. 210 00:07:42,722 --> 00:07:44,824 BUT ONE OF THE CARDINAL 211 00:07:44,824 --> 00:07:47,627 QUESTIONS OR CHALLENGES WE HAD 212 00:07:47,627 --> 00:07:49,729 INITIALLY WAS, HOW DO WE KNOW 213 00:07:49,729 --> 00:07:52,298 WHETHER THESE DATA ARE RELIABLE. 214 00:07:52,298 --> 00:07:54,400 THESE DATA HAD NEVER BEEN USED 215 00:07:54,400 --> 00:07:55,902 BEFORE USING OPEN CLAIMS THAT 216 00:07:55,902 --> 00:07:57,303 WERE SO RECENT. 217 00:07:57,303 --> 00:07:59,472 SO WE DID SOME QUALITY CONTROL 218 00:07:59,472 --> 00:08:01,107 ANALYSES AND WHAT WE FOUND IS 219 00:08:01,107 --> 00:08:02,608 IF WE WAITED FOR JUST TWO 220 00:08:02,608 --> 00:08:04,610 MONTHS TO USE THE DATA, THAT 221 00:08:04,610 --> 00:08:07,713 WAS A SWEET SPOT THAT GAVE US 222 00:08:07,713 --> 00:08:10,283 THE OPTIMAL BALANCE BETWEEN 223 00:08:10,283 --> 00:08:12,385 DATA ACCURACY AND RECENCY. 224 00:08:12,385 --> 00:08:16,956 AND THEN ANOTHER CHALLENGE WE 225 00:08:16,956 --> 00:08:19,058 HAD HOW DO WE IDENTIFY PATIENTS 226 00:08:19,058 --> 00:08:19,826 WITH COVID-19 IN THESE 227 00:08:19,826 --> 00:08:21,427 DATABASES. 228 00:08:21,427 --> 00:08:23,796 NOT ALL DATABASES HAVE LAB DATA. 229 00:08:23,796 --> 00:08:30,970 EARLY ON WE PERFORMED A STUDY 230 00:08:30,970 --> 00:08:35,408 PUBLISHED IN JAHMA, A RELEASED 231 00:08:35,408 --> 00:08:38,478 DIAGNOSIS CODE FOR COVID-19, WE 232 00:08:38,478 --> 00:08:40,813 EVALUATED AGAINST THE GOLD 233 00:08:40,813 --> 00:08:42,415 STANDARD THAT WAS PCR DATA. 234 00:08:42,415 --> 00:08:52,959 WHAT WE FOUND IS THAT DIAGNOSIS 235 00:08:53,192 --> 00:08:54,760 CODE WAS 95%, FOR THOSE WHO USE 236 00:08:54,760 --> 00:08:57,363 THIS DATA THIS IS AN EXCELLENT 237 00:08:57,363 --> 00:08:58,965 RELIABILITY YOU CAN GET FOR A 238 00:08:58,965 --> 00:09:02,268 BILLING CODE FOR AN ENTITY. 239 00:09:02,268 --> 00:09:04,036 PROBABLY BECAUSE COVID-19 IS 240 00:09:04,036 --> 00:09:05,238 BLACK AND WHITE. 241 00:09:05,238 --> 00:09:06,806 EITHER YOU HAVE IT OR DON'T 242 00:09:06,806 --> 00:09:07,707 HAVE IT DEPENDING ON THE LAB 243 00:09:07,707 --> 00:09:08,441 TEST. 244 00:09:08,441 --> 00:09:10,042 ONE OF THE ADVANTAGES OF THIS 245 00:09:10,042 --> 00:09:11,210 INVESTIGATION NOT ONLY CONVINCE 246 00:09:11,210 --> 00:09:13,312 US WE COULD USE THESE DATA TO 247 00:09:13,312 --> 00:09:14,981 ANSWER OUR QUESTIONS BUT WE 248 00:09:14,981 --> 00:09:17,550 ALSO FELT WE VICARIOUSLY 249 00:09:17,550 --> 00:09:18,951 CONTRIBUTED TO MANY OTHER 250 00:09:18,951 --> 00:09:19,919 PEOPLE'S INVESTIGATIONS THAT 251 00:09:19,919 --> 00:09:21,921 HUNG THEIR HAT ON OUR 252 00:09:21,921 --> 00:09:23,556 VALIDATION. 253 00:09:23,556 --> 00:09:26,125 OUR NEXT CHALLENGE WAS HOW DO 254 00:09:26,125 --> 00:09:28,227 WE IDENTIFY THE STRAIN THAT IS 255 00:09:28,227 --> 00:09:29,695 POSED BY TOO MANY PATIENTS IN 256 00:09:29,695 --> 00:09:31,030 HOSPITALS? 257 00:09:31,030 --> 00:09:33,633 IT IS A NEBULOUS CONCEPT. 258 00:09:33,633 --> 00:09:36,369 IN THE PAST INVESTIGATORS HAVE 259 00:09:36,369 --> 00:09:37,803 USED THINGS LIKE, 20% ABOVE 260 00:09:37,803 --> 00:09:41,407 CAPACITY. 261 00:09:41,407 --> 00:09:43,009 30% ABOVE CONSENSUS CAPACITY. 262 00:09:43,009 --> 00:09:44,243 THAT ASSUMES THAT ALL PATIENTS 263 00:09:44,243 --> 00:09:45,378 ARE THE SAME. 264 00:09:45,378 --> 00:09:47,346 BUT THAT'S NOT TRUE. 265 00:09:47,346 --> 00:09:49,348 PATIENTS MAY HAVE DIFFERENT 266 00:09:49,348 --> 00:09:50,950 SEVERITY, LINKED TO DIFFERENT 267 00:09:50,950 --> 00:09:51,784 RESOURCE NEEDS AND PERSONNEL 268 00:09:51,784 --> 00:09:52,618 NEEDS. 269 00:09:52,618 --> 00:09:54,921 SO FOR THAT REASON, WE CREATED 270 00:09:54,921 --> 00:09:57,623 A NOVEL SURGE INDEX TO ELICIT 271 00:09:57,623 --> 00:10:00,092 THAT. 272 00:10:00,092 --> 00:10:01,928 THE NUMERATOR INCLUDES EVERYONE 273 00:10:01,928 --> 00:10:03,496 WITH COVID ADMITTED TO HOSPITAL 274 00:10:03,496 --> 00:10:05,865 IN A GIVEN MONTH. 275 00:10:05,865 --> 00:10:07,833 EXCEPT THEY ARE WEIGHTED BY 276 00:10:07,833 --> 00:10:09,468 THEIR SEVERITY LINKED TO THE 277 00:10:09,468 --> 00:10:12,405 NEEDS FOR NURSING AND INCREASED 278 00:10:12,405 --> 00:10:13,339 NEEDS FOR RESPIRATORY 279 00:10:13,339 --> 00:10:16,342 THERAPISTS, THE TWO MOST 280 00:10:16,342 --> 00:10:17,210 PRECIOUS PERSONNEL COMMODITIES 281 00:10:17,210 --> 00:10:19,212 DURING THE PANDEMIC. 282 00:10:19,212 --> 00:10:22,014 WE NORMALIZED THAT NUMERATOR BY 283 00:10:22,014 --> 00:10:22,848 THE PRE-COVID NOMINAL BED 284 00:10:22,848 --> 00:10:24,116 CAPACITY. 285 00:10:24,116 --> 00:10:25,084 HOW MANY BED HOSPITAL DO YOU 286 00:10:25,084 --> 00:10:27,620 HAVE. 287 00:10:27,620 --> 00:10:30,423 WHAT THAT DID WAS, IT ALLOWED 288 00:10:30,423 --> 00:10:32,058 US TO COMPARE STRAIN ACROSS 289 00:10:32,058 --> 00:10:34,627 HOSPITALS IN THE U.S. THAT HAD 290 00:10:34,627 --> 00:10:35,127 DIFFERENT BASELINE 291 00:10:35,127 --> 00:10:36,696 INFRASTRUCTURE AND CAPACITY. 292 00:10:36,696 --> 00:10:37,897 LET ME EXPLAIN THIS WITH AN 293 00:10:37,897 --> 00:10:39,065 EXAMPLE. 294 00:10:39,065 --> 00:10:41,634 LET'S ASSUME THERE ARE TWO 295 00:10:41,634 --> 00:10:44,170 HOSPITALS, HOSPITAL A, BIGGER 296 00:10:44,170 --> 00:10:47,306 100-BED HOSPITAL, HOSPITAL B IS 297 00:10:47,306 --> 00:10:56,349 SMALLER 50-BED. 298 00:10:56,349 --> 00:10:58,517 LET'S ASSUME JUNE, THE 20 299 00:10:58,517 --> 00:11:00,219 PATIENTS WHO HIT THE SMALL 300 00:11:00,219 --> 00:11:02,455 HOSPITAL WERE VENTILATED. 301 00:11:02,455 --> 00:11:03,689 ALTHOUGH BOTH HOSPITALS HAD 20 302 00:11:03,689 --> 00:11:04,957 PATIENTS HIT THE HOSPITAL AT 303 00:11:04,957 --> 00:11:06,859 THE SAME TIME, THE STRAIN THAT 304 00:11:06,859 --> 00:11:12,031 WAS ENCOUNTERED BY THE SECOND 305 00:11:12,031 --> 00:11:16,602 SMALLER HOSPITAL WHO SAW MORE 306 00:11:16,602 --> 00:11:20,006 SEVERE CASES WAS MUCH HEAVIER. 307 00:11:20,006 --> 00:11:21,641 EACH CIRCLE REPRESENTS A SINGLE 308 00:11:21,641 --> 00:11:24,477 HOSPITAL IN A GIVEN MONTH, AND 309 00:11:24,477 --> 00:11:25,645 COLOR CODED BY REGION. 310 00:11:25,645 --> 00:11:27,513 YOU COULD SEE THERE WAS A GREAT 311 00:11:27,513 --> 00:11:29,849 VARIATION IN THE AMOUNT OF 312 00:11:29,849 --> 00:11:30,516 STRAIN ENCOUNTERED BY DIFFERENT 313 00:11:30,516 --> 00:11:31,951 HOSPITALS. 314 00:11:31,951 --> 00:11:34,287 BECAUSE ON THE Y INDEX, THE 315 00:11:34,287 --> 00:11:40,326 SURGE INDEX IS ON THE 316 00:11:40,326 --> 00:11:42,795 LOGARITHMIC SCALE. 317 00:11:42,795 --> 00:11:44,730 WE TRIED TO ACCOUNT FOR 318 00:11:44,730 --> 00:11:46,499 HOSPITAL RELATED AND TIME 319 00:11:46,499 --> 00:11:49,068 RELATED FACTORS TO TRY TO 320 00:11:49,068 --> 00:11:52,838 UNDERSTAND BETWEEN SURGE INDEX 321 00:11:52,838 --> 00:11:56,676 AND MORTALITY RISK. 322 00:11:56,676 --> 00:11:59,211 MORTALITY WENT UP AS HOSPITALS 323 00:11:59,211 --> 00:12:01,814 HIT HIGHER PERCENTILES. 324 00:12:01,814 --> 00:12:05,384 NOT ONLY THAT, OBSERVATION IS 325 00:12:05,384 --> 00:12:06,085 OBVIOUSLY MOVING. 326 00:12:06,085 --> 00:12:07,720 BUT AT THE SAME TIME, IF YOU 327 00:12:07,720 --> 00:12:09,588 HAVE THE TOP LAYER OF THE SURGE 328 00:12:09,588 --> 00:12:11,891 INDEX WHERE YOU HAVE THE 329 00:12:11,891 --> 00:12:13,125 MAXIMUM NUMBER OF PEOPLE IN THE 330 00:12:13,125 --> 00:12:14,960 HOSPITAL, THERE'S A LOT OF 331 00:12:14,960 --> 00:12:16,429 DEATHS, THE ABSOLUTE RISK IS 332 00:12:16,429 --> 00:12:17,496 ALSO PRETTY HIGH. 333 00:12:17,496 --> 00:12:20,366 WE WERE ABLE TO EVIDENCE USING 334 00:12:20,366 --> 00:12:21,534 STRUCTURAL MODELS WHERE WE 335 00:12:21,534 --> 00:12:23,869 FOUND A VERY MOVING STATISTIC 336 00:12:23,869 --> 00:12:26,472 THAT ONE IN EVERY FOUR COVID-19 337 00:12:26,472 --> 00:12:28,107 HOSPITAL DEATHS MAY HAVE BEEN 338 00:12:28,107 --> 00:12:29,442 RELATED TO OVER CROWDING. 339 00:12:29,442 --> 00:12:31,844 THIS WAS SORT OF A MONUMENTAL 340 00:12:31,844 --> 00:12:34,413 FINDING BECAUSE IT CAME OUT 341 00:12:34,413 --> 00:12:36,549 DURING THE PANDEMIC AND DELTA 342 00:12:36,549 --> 00:12:37,817 VARIANCE WHERE HOSPITALS WERE 343 00:12:37,817 --> 00:12:40,086 STRAINING AND IT LED TO MANY 344 00:12:40,086 --> 00:12:41,954 HOSPITAL LEADERS AND MANY 345 00:12:41,954 --> 00:12:44,256 PEOPLE WITHIN ASPER AND 346 00:12:44,256 --> 00:12:45,224 HOSPITAL PREPAREDNESS PROGRAM 347 00:12:45,224 --> 00:12:47,993 UNDERSTAND THE IMPORTANCE OF 348 00:12:47,993 --> 00:12:49,161 DECOMPRESSING HOSPITALS WITH 349 00:12:49,161 --> 00:12:51,464 LOAD BALANCING SO NO SINGLE 350 00:12:51,464 --> 00:12:52,898 HOSPITAL WAS COMPROMISED. 351 00:12:52,898 --> 00:12:54,967 OUR BOTTOM LINE IS OVER 352 00:12:54,967 --> 00:12:57,269 CROWDING KILLS AND LOAD 353 00:12:57,269 --> 00:13:00,206 BALANCING MIGHT SAVE LIVES. 354 00:13:00,206 --> 00:13:02,742 SENIOR FELLOW IN OUR DEPARTMENT 355 00:13:02,742 --> 00:13:04,610 TOOK ON THE RESPONSIBILITY 356 00:13:04,610 --> 00:13:05,611 DOING A SYSTEMATIC REVIEW TO 357 00:13:05,611 --> 00:13:10,249 TRY TO LOOK AT THE STUDIES THAT 358 00:13:10,249 --> 00:13:11,350 COMPARED CASELOADS, STRAINS AND 359 00:13:11,350 --> 00:13:14,420 OUTCOMES. 360 00:13:14,420 --> 00:13:17,990 HE FOUND 39 STUDIES THAT FOUND 361 00:13:17,990 --> 00:13:19,258 A DETRIMENTAL IMPACT. 362 00:13:19,258 --> 00:13:21,160 I THINK THE MORE IMPORTANT 363 00:13:21,160 --> 00:13:23,729 IMPACT FROM THE STUDY IS 37 OF 364 00:13:23,729 --> 00:13:34,273 THE 39 STUDIES USED INDEPENDENT 365 00:13:37,042 --> 00:13:39,145 UNIQUE METRICS THERE WAS NO 366 00:13:39,145 --> 00:13:41,547 DATA FROM LOW INCOME COUNTRIES. 367 00:13:41,547 --> 00:13:43,549 WE NEED A CONSENSUS FRAMEWORK 368 00:13:43,549 --> 00:13:45,684 FOR DEFINING SURGE STRAIN TO 369 00:13:45,684 --> 00:13:46,886 MONITOR, COMPARE, TRIAGE AND 370 00:13:46,886 --> 00:13:48,254 MITIGATE FOR THE FUTURE. 371 00:13:48,254 --> 00:13:49,889 AND IT SHOULD ALSO BE SCALABLE 372 00:13:49,889 --> 00:13:51,524 TO THE DEVELOPING WORLD SO WE 373 00:13:51,524 --> 00:13:53,392 CAN UNDERSTAND THE IMPACTS OF 374 00:13:53,392 --> 00:13:55,694 STRAIN ON A GLOBAL SCALE. 375 00:13:55,694 --> 00:13:58,497 OUR NEXT OBVIOUS QUESTION WAS, 376 00:13:58,497 --> 00:14:00,833 WE FOUND THAT SURGING HOSPITALS 377 00:14:00,833 --> 00:14:01,634 INCREASED MORTALITY OF THEIR 378 00:14:01,634 --> 00:14:02,701 PATIENTS. 379 00:14:02,701 --> 00:14:04,437 BUT WE LOOKED AT IT AT AN 380 00:14:04,437 --> 00:14:06,172 AGGREGATE LEVEL. 381 00:14:06,172 --> 00:14:08,374 WE KNOW HOSPITALS VARY IN THEIR 382 00:14:08,374 --> 00:14:08,941 CAPABILITIES, PROVISIONS OF 383 00:14:08,941 --> 00:14:09,442 CARE. 384 00:14:09,442 --> 00:14:11,310 MAYBE THAT HAS AN IMPACT AND 385 00:14:11,310 --> 00:14:14,380 MAYBE THE LARGER MORE EQUIPPED 386 00:14:14,380 --> 00:14:15,047 HOSPITALS, CENTERS OF 387 00:14:15,047 --> 00:14:16,282 EXCELLENCE ARE MAYBE MORE 388 00:14:16,282 --> 00:14:18,384 RESILIENCE. 389 00:14:18,384 --> 00:14:20,753 TO ASK THAT WE RAN AN 390 00:14:20,753 --> 00:14:21,854 INTERACTION ANALYSIS. 391 00:14:21,854 --> 00:14:23,722 WHAT WE FOUND, WHETHER YOU WERE 392 00:14:23,722 --> 00:14:28,093 A SMALL OR BIG HOSPITAL, 393 00:14:28,093 --> 00:14:29,495 MULTI-I.C.U. OR SINGLE I.C.U., 394 00:14:29,495 --> 00:14:33,699 ONE THAT DOES ECMO OR NO, 395 00:14:33,699 --> 00:14:36,869 SURGES WERE DETRIMENTAL TO 396 00:14:36,869 --> 00:14:37,736 SURVIVAL. 397 00:14:37,736 --> 00:14:39,605 WHAT IT TELLS ME, WE SHOULD 398 00:14:39,605 --> 00:14:42,007 PROBABLY LOAD BALANCE 399 00:14:42,007 --> 00:14:44,343 ACROSS-THE-BOARD AND IN THAT 400 00:14:44,343 --> 00:14:46,212 WAY, WE CAN MAKE SURE SMALL 401 00:14:46,212 --> 00:14:47,847 HOSPITALS HAVE THE PROVISION TO 402 00:14:47,847 --> 00:14:49,515 SEND PATIENTS THEY CAN'T TAKE 403 00:14:49,515 --> 00:14:51,617 CARE OF AT OTHER HOSPITALS AND 404 00:14:51,617 --> 00:14:52,818 LARGE CENTERS OF EXCELLENCE CAN 405 00:14:52,818 --> 00:14:55,921 CONTINUE TO NOT BE INUNDATED BY 406 00:14:55,921 --> 00:14:57,256 MUNDANE CASES AND THEY CAN 407 00:14:57,256 --> 00:14:59,124 FOCUS ON THE MORE COMPLEX CASES 408 00:14:59,124 --> 00:15:00,926 ONLY THEY CAN TAKE CARE OF. 409 00:15:00,926 --> 00:15:06,565 SO THE BOTTOM LINE IS EARLY 410 00:15:06,565 --> 00:15:09,401 DECOMPRESSION OF LARGER CENTERS 411 00:15:09,401 --> 00:15:11,003 ACCEPT REFERRALS. 412 00:15:11,003 --> 00:15:12,872 THE NEXT OBVIOUS QUESTION WAS, 413 00:15:12,872 --> 00:15:14,440 WE FOUND THAT SURGES ARE 414 00:15:14,440 --> 00:15:15,407 DETRIMENTAL. 415 00:15:15,407 --> 00:15:18,644 BUT THE NEXT STEP IS WE NEED TO 416 00:15:18,644 --> 00:15:20,746 MOVE THESE PATIENTS OUTSIDE. 417 00:15:20,746 --> 00:15:22,848 INITIALLY NOBODY KNEW IF IT WAS 418 00:15:22,848 --> 00:15:25,084 SAFE TO MOVE A COVID PATIENT 419 00:15:25,084 --> 00:15:28,020 FROM ONE HOSPITAL TO THE OTHER. 420 00:15:28,020 --> 00:15:30,589 ONE OF MY MENTEES WHO TRAINED 421 00:15:30,589 --> 00:15:33,158 AS A STAFF CLINICIAN, SHE USED 422 00:15:33,158 --> 00:15:34,793 A NATIONAL E.M.S. DATABASE TO 423 00:15:34,793 --> 00:15:38,764 ASK THE QUESTION, HOW OFTEN DO 424 00:15:38,764 --> 00:15:40,733 PATIENTS DECOMPENSATE DURING 425 00:15:40,733 --> 00:15:44,270 GROUND OR AIR TRANSPORT IF THEY 426 00:15:44,270 --> 00:15:46,372 HAVE ACUTE RESPIRATORY ILLNESS. 427 00:15:46,372 --> 00:15:49,041 THIS STUDY WAS FOUND IN JAMA. 428 00:15:49,041 --> 00:15:51,710 WHAT SHE FOUND, THE MORE 429 00:15:51,710 --> 00:15:53,812 IMPORTANT POINT, THE RISK WAS 430 00:15:53,812 --> 00:15:55,915 NO GREATER DURING THE PANDEMIC 431 00:15:55,915 --> 00:15:58,851 MOVING THESE PATIENTS COMPARED 432 00:15:58,851 --> 00:16:00,319 TO PRE-PANDEMIC. 433 00:16:00,319 --> 00:16:02,655 THAT TOLD US PERHAPS CLINICIANS 434 00:16:02,655 --> 00:16:05,024 DO A PRETTY GOOD JOB WHO GETS 435 00:16:05,024 --> 00:16:07,393 MOVED AND SAFE TO MOVE. 436 00:16:07,393 --> 00:16:13,632 THIS ENCOURAGED THE SENTIMENT 437 00:16:13,632 --> 00:16:16,001 IN TERMS OF MOVING PATIENTS TO 438 00:16:16,001 --> 00:16:16,569 OTHER HOSPITALS DURING THE 439 00:16:16,569 --> 00:16:17,870 PANDEMIC. 440 00:16:17,870 --> 00:16:20,739 WHILE THAT MAY BE HELPFUL IN 441 00:16:20,739 --> 00:16:21,907 THEORY, CAN YOU REALLY LOAD 442 00:16:21,907 --> 00:16:23,542 BALANCE WHEN ALL THE HOSPITALS 443 00:16:23,542 --> 00:16:25,377 ARE INUNDATED. 444 00:16:25,377 --> 00:16:34,753 TO ADDRESS THIS, DR. SARZYNSKI 445 00:16:34,753 --> 00:16:36,855 USED THE PREMIER DATABASE, WERE 446 00:16:36,855 --> 00:16:39,425 HOSPITALS ABLE TO FLEX THEIR 447 00:16:39,425 --> 00:16:40,359 CAPABILITY MOVING PATIENTS 448 00:16:40,359 --> 00:16:40,859 OUTSIDE MORE THAN THEIR 449 00:16:40,859 --> 00:16:41,527 BASELINE. 450 00:16:41,527 --> 00:16:43,329 WHAT YOU SEE IS A HEAT BAR AT 451 00:16:43,329 --> 00:16:44,597 THE TOP. 452 00:16:44,597 --> 00:16:46,966 THE MORE YELLOW, THE GREATER 453 00:16:46,966 --> 00:16:48,267 THE PROPORTION OF HOSPITALS 454 00:16:48,267 --> 00:16:50,235 THAT WERE SURGING. 455 00:16:50,235 --> 00:16:53,005 THE TREND LINE REPRESENTS THE 456 00:16:53,005 --> 00:16:58,677 CUMULATIVE TOTAL OF TRANSFERS 457 00:16:58,677 --> 00:16:59,211 BETWEEN HOSPITALS FOR 600 458 00:16:59,211 --> 00:17:00,980 HOSPITALS. 459 00:17:00,980 --> 00:17:02,815 IN THE PRE-PANDEMIC PERIOD IT'S 460 00:17:02,815 --> 00:17:03,816 PRETTY STABLE. 461 00:17:03,816 --> 00:17:05,684 THE TRANSFER RATE. 462 00:17:05,684 --> 00:17:06,885 AND IT FLUCTUATES DURING THE 463 00:17:06,885 --> 00:17:07,152 PANDEMIC. 464 00:17:07,152 --> 00:17:09,622 MOST OF THE TIME IT'S DIPPING. 465 00:17:09,622 --> 00:17:11,457 THE DIPS ARE WHEN HOSPITALS ARE 466 00:17:11,457 --> 00:17:12,424 SURGING MORE. 467 00:17:12,424 --> 00:17:14,526 IT'S KIND OF PARADOXICAL, BUT 468 00:17:14,526 --> 00:17:16,362 THERE'S A NEED DURING SURGES 469 00:17:16,362 --> 00:17:17,863 BUT THERE'S LESS MOVEMENT OF 470 00:17:17,863 --> 00:17:23,902 PATIENTS DURING THAT. 471 00:17:23,902 --> 00:17:27,973 NOT ONLY THAT, THE BARS 472 00:17:27,973 --> 00:17:28,707 REPRESENT PRE-PANDEMIC TO 473 00:17:28,707 --> 00:17:30,309 PANDEMIC TRANSFERS. 474 00:17:30,309 --> 00:17:31,710 WE KNOW SMALL HOSPITALS DON'T 475 00:17:31,710 --> 00:17:33,712 HAVE CAPABILITIES AND THEY NEED 476 00:17:33,712 --> 00:17:35,147 TO SEND PATIENTS OUTSIDE FOR 477 00:17:35,147 --> 00:17:35,948 HIGHER LEVELS OF CARE. 478 00:17:35,948 --> 00:17:38,250 YOU COULD SEE THE DISPARITY, 479 00:17:38,250 --> 00:17:42,354 URBAN HOSPITALS WERE ABLE TO 480 00:17:42,354 --> 00:17:44,123 FLEX MORE 50% BASELINE 481 00:17:44,123 --> 00:17:45,290 CAPABILITIES TO TRANSFER. 482 00:17:45,290 --> 00:17:46,592 RURAL WERE NOT. 483 00:17:46,592 --> 00:17:48,327 IT'S COMPLETELY FLAT. 484 00:17:48,327 --> 00:17:50,429 THE BOTTOM LINE, WE NEED 485 00:17:50,429 --> 00:17:52,798 COUNTERMEASURES IN THE FUTURE 486 00:17:52,798 --> 00:18:01,707 AGAINST TRANSFER BARRIERS IN 487 00:18:01,707 --> 00:18:02,708 RURAL AREAS TO MAINTAIN CARE 488 00:18:02,708 --> 00:18:04,243 ABILITY. 489 00:18:04,243 --> 00:18:09,882 THE NEXT IS RELATED TO COVID 490 00:18:09,882 --> 00:18:10,749 VACCINE HESITANCY. 491 00:18:10,749 --> 00:18:12,651 WE WERE ON THE FRONT LINE 492 00:18:12,651 --> 00:18:13,952 TAKING CARE OF PATIENTS WHO DID 493 00:18:13,952 --> 00:18:15,988 EVERYTHING RIGHT. 494 00:18:15,988 --> 00:18:18,791 THEY GOT FULLY VACCINATED BUT 495 00:18:18,791 --> 00:18:20,926 THEY HAD UNDERLYING PROBLEMS 496 00:18:20,926 --> 00:18:23,462 THAT RESULTED IN THEM NOT 497 00:18:23,462 --> 00:18:26,265 MOUNTING AN IMMUNE RESPONSE. 498 00:18:26,265 --> 00:18:28,834 THEIR BODY WOULD BEHAVE LIKE AN 499 00:18:28,834 --> 00:18:29,468 UNVACCINATED PATIENT AND THEY 500 00:18:29,468 --> 00:18:31,403 WOULD DIE. 501 00:18:31,403 --> 00:18:33,906 AND OTHERS AT HOME WHO WOULDN'T 502 00:18:33,906 --> 00:18:35,407 GET VACCINATED WHO POSED A RISK 503 00:18:35,407 --> 00:18:37,943 TO THESE PATIENTS. 504 00:18:37,943 --> 00:18:38,911 WHY IS THIS MOVEMENT NOT 505 00:18:38,911 --> 00:18:40,946 HAPPENING? 506 00:18:40,946 --> 00:18:43,282 WHAT WE REALIZED WAS PERHAPS WE 507 00:18:43,282 --> 00:18:45,684 NEED TO SHOW PEOPLE MORE THAN 508 00:18:45,684 --> 00:18:48,253 JUST THIS TRIAL IS 60% 509 00:18:48,253 --> 00:18:50,122 EFFECTIVE, THIS TRIAL IS 510 00:18:50,122 --> 00:18:51,890 SHOWING THIS VACCINE IS 70% 511 00:18:51,890 --> 00:18:53,759 EFFECTIVE. 512 00:18:53,759 --> 00:18:55,160 MAYBE THE COUNTRY ISN'T MOVED 513 00:18:55,160 --> 00:18:57,029 BY THAT AND MAYBE THEY WOULD BE 514 00:18:57,029 --> 00:18:58,464 MOVED BY ABSOLUTE RISK. 515 00:18:58,464 --> 00:19:04,470 WE COLLABORATED WITH THE CDC 516 00:19:04,470 --> 00:19:14,913 AND DID THIS NMWR LED BY 517 00:19:15,581 --> 00:19:17,616 CHRISTINA YEK AND SARAH WARNER. 518 00:19:17,616 --> 00:19:20,619 WHAT WE FOUND OUT OF 1.2 519 00:19:20,619 --> 00:19:22,054 MILLION FULLY VACCINATED IN THE 520 00:19:22,054 --> 00:19:24,823 U.S., THE RISK OF DYING WITH 521 00:19:24,823 --> 00:19:27,459 BREAK THROUGH ILLNESS IS LESS 522 00:19:27,459 --> 00:19:28,761 THAN 1 IN 33,000. 523 00:19:28,761 --> 00:19:30,262 THIS IS A PERSON WHO WOULD MOVE 524 00:19:30,262 --> 00:19:33,532 A PERSON ON THE STREET AND HAVE 525 00:19:33,532 --> 00:19:35,000 THEM GO TO CVS AND GET 526 00:19:35,000 --> 00:19:37,069 VACCINATED, WE THOUGHT. 527 00:19:37,069 --> 00:19:39,404 WHAT HELPED IS MORE THAN 200 528 00:19:39,404 --> 00:19:41,507 NEWS OUTLETS TOOK OUR FINDINGS 529 00:19:41,507 --> 00:19:43,142 AND DISSEMINATED TO THE PUBLIC. 530 00:19:43,142 --> 00:19:44,510 INCLUDING SOME OF THESE TOP 531 00:19:44,510 --> 00:19:45,978 NEWS OUTLETS. 532 00:19:45,978 --> 00:19:52,217 THE FORMER DIRECTOR OF THE CDC 533 00:19:52,217 --> 00:19:54,753 RACHEL VALENSKI WENT ON AND 534 00:19:54,753 --> 00:19:55,754 PROMOTED OUR MESSAGE WHICH WAS 535 00:19:55,754 --> 00:19:57,289 HELPFUL. 536 00:19:57,289 --> 00:19:59,191 THE ABSOLUTE LOW RISK IN A 537 00:19:59,191 --> 00:20:00,826 POPULATION IS OFTEN NOT 538 00:20:00,826 --> 00:20:03,228 DISCERNABLE TO THE PUBLIC IN 539 00:20:03,228 --> 00:20:04,863 VACCINE TRIALS AND REAL WORLD 540 00:20:04,863 --> 00:20:07,466 DATA CAN HELP FILL THAT GAP. 541 00:20:07,466 --> 00:20:10,035 FINALLY, WE ASKED THE QUESTIONS 542 00:20:10,035 --> 00:20:11,937 OUR PROGNOSTIC SCORES FOR 543 00:20:11,937 --> 00:20:13,338 COVID-19 RELIABLE FOR TRIAGE? 544 00:20:13,338 --> 00:20:15,440 WE WHO ARE WORKING ON THE FRONT 545 00:20:15,440 --> 00:20:17,309 LINE IN CRITICAL CARE UNITS 546 00:20:17,309 --> 00:20:18,944 WERE REALLY WORRIED THAT A 547 00:20:18,944 --> 00:20:21,280 PERIOD WOULD COME WHERE WE HAVE 548 00:20:21,280 --> 00:20:23,348 TWO PATIENTS AND ONE VENTILATOR 549 00:20:23,348 --> 00:20:25,117 AND WE NEED TO DECIDE WHO TO 550 00:20:25,117 --> 00:20:27,786 GIVE IT TO. 551 00:20:27,786 --> 00:20:28,720 FORTUNATELY THAT SCENARIO 552 00:20:28,720 --> 00:20:29,421 DIDN'T REALLY OCCUR IN OUR 553 00:20:29,421 --> 00:20:30,622 COUNTRY. 554 00:20:30,622 --> 00:20:34,459 HOWEVER, THERE WAS A LOT OF 555 00:20:34,459 --> 00:20:36,161 IMPLICIT TRIAGE. 556 00:20:36,161 --> 00:20:38,263 WE HAD HIGHER BARS FOR PATIENTS 557 00:20:38,263 --> 00:20:40,732 TO GO TO THE I.C.U., I'M SURE 558 00:20:40,732 --> 00:20:45,304 MANY SUFFERS IN THE BARGAIN. 559 00:20:45,304 --> 00:20:46,238 TRIAGE ALGORITHMS HAD ALREADY 560 00:20:46,238 --> 00:20:48,373 BEEN SET UP BY SEVERAL STATES. 561 00:20:48,373 --> 00:20:50,108 WE WANTED TO CRITICALLY 562 00:20:50,108 --> 00:20:51,343 APPRAISE WHETHER THESE ARE 563 00:20:51,343 --> 00:20:58,784 RELIABLE OR NOT. 564 00:20:58,784 --> 00:21:00,853 MIKE KELLER, WHAT HE FOUND WAS 565 00:21:00,853 --> 00:21:06,391 FIRST OF ALL, THE SOFA SCORE, 566 00:21:06,391 --> 00:21:07,559 SEQUENTIAL ORGAN FAILURE SCORE, 567 00:21:07,559 --> 00:21:09,761 TO KNOW HOW SICK THEY ARE ON A 568 00:21:09,761 --> 00:21:12,297 GIVEN DAY, THAT WAS A SCORE. 569 00:21:12,297 --> 00:21:14,666 NOT COVID SPECIFIC, IT WAS USED 570 00:21:14,666 --> 00:21:16,802 AND IMPLEMENTED IN SEVERAL 571 00:21:16,802 --> 00:21:18,770 STATES, CRISIS STANDARDS OF 572 00:21:18,770 --> 00:21:19,638 CARE ALGORITHM, THE ONES 573 00:21:19,638 --> 00:21:20,906 COLORED IN RED. 574 00:21:20,906 --> 00:21:23,475 BUT WHEN WE LOOKED IN REAL 575 00:21:23,475 --> 00:21:24,910 WORLD DATA WE FOUND THE AREA 576 00:21:24,910 --> 00:21:27,546 UNDER THE CURVE, THE C 577 00:21:27,546 --> 00:21:32,150 STATISTIC FOR PREDICTING 578 00:21:32,150 --> 00:21:33,785 MORTALITY IN INTUBATED PATIENT 579 00:21:33,785 --> 00:21:35,087 IS REALLY AS GOOD AS FLIPPING A 580 00:21:35,087 --> 00:21:36,622 COIN. 581 00:21:36,622 --> 00:21:38,023 THERE'S A POORLY PERFORMING 582 00:21:38,023 --> 00:21:39,892 METRIC USED BY MOST STATES AND 583 00:21:39,892 --> 00:21:42,461 HAD WE USED THIS, WE WOULD HAVE 584 00:21:42,461 --> 00:21:46,498 MISTRIAGED SO MANY PEOPLE. 585 00:21:46,498 --> 00:21:49,534 NOW THE NEXT STEP WAS TO TRY TO 586 00:21:49,534 --> 00:21:53,005 FIND A COVID-SPECIFIC 587 00:21:53,005 --> 00:21:54,606 PROGNOSTIC SCORE, THE MODIFIED 588 00:21:54,606 --> 00:21:55,707 SCORE PERFORMED WELL IN THE 589 00:21:55,707 --> 00:21:57,709 FIRST WAVE. 590 00:21:57,709 --> 00:22:00,245 BUT DR. YEK SHOWED IN THIS 591 00:22:00,245 --> 00:22:04,416 STUDY, OVER TIME, THE COVID 592 00:22:04,416 --> 00:22:06,485 SPECIFIC PROGNOSTIC SCORE 593 00:22:06,485 --> 00:22:07,486 DECAYED OVERTIME TO SHOW 594 00:22:07,486 --> 00:22:12,024 PREDICTABILITY. 595 00:22:12,024 --> 00:22:13,926 COVID WHICH EVOLVED AND 596 00:22:13,926 --> 00:22:14,860 TREATMENTS CHANGED OVER TIME 597 00:22:14,860 --> 00:22:17,229 AND OUR ABILITY TO PROTECT 598 00:22:17,229 --> 00:22:18,196 AGAINST THE DISEASE CHANGED 599 00:22:18,196 --> 00:22:19,398 OVER TIME. 600 00:22:19,398 --> 00:22:20,699 ALL THAT PROBABLY HAD AN 601 00:22:20,699 --> 00:22:23,235 IMPORTANT ROLE IN CHANGING THE 602 00:22:23,235 --> 00:22:24,403 ABILITY TO PREDICT MORTALITY. 603 00:22:24,403 --> 00:22:28,340 SO IN THE FUTURE WE NEED TO BE 604 00:22:28,340 --> 00:22:29,942 MINDFUL OF FREQUENTLY 605 00:22:29,942 --> 00:22:31,109 REAPPRAISING THE ACCURACY OF 606 00:22:31,109 --> 00:22:32,945 SOME OF THESE CODES. 607 00:22:32,945 --> 00:22:35,314 SO IN SUMMARY, HOSPITAL OVER 608 00:22:35,314 --> 00:22:36,481 CROWDING IS DETRIMENTAL TO 609 00:22:36,481 --> 00:22:38,583 HOSPITAL SURVIVAL. 610 00:22:38,583 --> 00:22:40,218 SCALABLE CONSENSUS DEFINITION 611 00:22:40,218 --> 00:22:42,354 IS NEEDED FOR CASELOAD STRAIN. 612 00:22:42,354 --> 00:22:45,657 MOVING PATIENTS BETWEEN 613 00:22:45,657 --> 00:22:47,259 HOSPITALS WAS RELATIVELY STAYED 614 00:22:47,259 --> 00:22:50,295 DURING THE PANDEMIC BUT 615 00:22:50,295 --> 00:22:50,862 CHALLENGING AMID WIDESPREAD 616 00:22:50,862 --> 00:22:55,634 SURGE. 617 00:22:55,634 --> 00:22:57,569 TOOLS ARE OBSCURE AND WARRANT 618 00:22:57,569 --> 00:22:58,437 REAPPRAISAL. 619 00:22:58,437 --> 00:23:00,772 IN THE FUTURE WE HOPE TO 620 00:23:00,772 --> 00:23:01,807 IMPROVE CARE QUALITY DURING 621 00:23:01,807 --> 00:23:02,607 OUTBREAKS. 622 00:23:02,607 --> 00:23:05,677 WE HOPE TO HAVE A SCALABLE 623 00:23:05,677 --> 00:23:10,782 CONSENSUS OF CASELOAD STRAIN. 624 00:23:10,782 --> 00:23:12,684 WE HOPE TO OPTIMIZE ON A DAILY 625 00:23:12,684 --> 00:23:15,520 BASIS AND HOPE TO GENERATE 626 00:23:15,520 --> 00:23:18,090 DATA-DRIVEN SOLUTIONS TO INFORM 627 00:23:18,090 --> 00:23:19,758 CRITICAL HEALTHCARE LEGISLATION 628 00:23:19,758 --> 00:23:20,559 AND POLICY IN DISASTER 629 00:23:20,559 --> 00:23:22,094 PREPAREDNESS. 630 00:23:22,094 --> 00:23:25,330 I'M VERY THANKFUL TO MY A-TEAM. 631 00:23:25,330 --> 00:23:26,965 MY LAB THAT WORKED DAY AND 632 00:23:26,965 --> 00:23:29,334 NIGHT DURING THE PANDEMIC TO 633 00:23:29,334 --> 00:23:31,603 GET YOU THESE IMPORTANT DATA. 634 00:23:31,603 --> 00:23:36,074 I NOW HAND OVER THE PODIUM TO 635 00:23:36,074 --> 00:23:38,677 DR. HICK AND I WOULD BE HAPPY 636 00:23:38,677 --> 00:23:39,911 TO ANSWER QUESTIONS AFTER. 637 00:23:39,911 --> 00:23:41,079 [APPLAUSE] 638 00:23:41,079 --> 00:23:46,585 >> John Hick: THANKS SO MUCH, 639 00:23:46,585 --> 00:23:49,454 I'M JOHN HICK FROM MINNEAPOLIS. 640 00:23:49,454 --> 00:23:52,024 I WANT TO THANK YOU ALL FOR 641 00:23:52,024 --> 00:23:54,192 ATTENDING FOR YOUR INTEREST IN 642 00:23:54,192 --> 00:23:55,894 THIS TOPIC AND FOR HAVING ME, 643 00:23:55,894 --> 00:23:56,995 IT'S A PRIVILEGE. 644 00:23:56,995 --> 00:23:59,197 I WILL GET STARTED WITH THIS 645 00:23:59,197 --> 00:24:00,565 FIRST SLIDE, IF I MAY. 646 00:24:00,565 --> 00:24:02,667 I WILL TAKE A BIT OF A POLICY 647 00:24:02,667 --> 00:24:05,904 TURN ON, THIS I WANT TO THANK 648 00:24:05,904 --> 00:24:07,806 SAMEER FOR PROVIDING SCIENTIFIC 649 00:24:07,806 --> 00:24:09,674 BASIS TO CONFIRM ANECDOTALLY 650 00:24:09,674 --> 00:24:12,010 WHAT WE KNEW TO BE TRUE ON THE 651 00:24:12,010 --> 00:24:12,978 GROUND BUT ALSO REINFORCE SOME 652 00:24:12,978 --> 00:24:16,481 OF THE THINGS THAT NEEDED TO BE 653 00:24:16,481 --> 00:24:17,416 REINFORCED, LIKE ESSENTIALLY 654 00:24:17,416 --> 00:24:19,918 LACK OF UTILITY OF SOFA SCORES 655 00:24:19,918 --> 00:24:21,186 IN PREDICTING OUTCOME. 656 00:24:21,186 --> 00:24:24,022 I FEEL A BIT GUILTY, IT WAS ONE 657 00:24:24,022 --> 00:24:25,157 OF MY INITIAL ARTICLES THAT 658 00:24:25,157 --> 00:24:31,763 DROVE THE STATE OF UTAH TO RELY 659 00:24:31,763 --> 00:24:32,564 ALMOST EXCLUSIVELY ON SOFA 660 00:24:32,564 --> 00:24:34,066 SCORES. 661 00:24:34,066 --> 00:24:35,667 TO THE DETRIMENT OF THOSE 662 00:24:35,667 --> 00:24:37,836 TRIAGE PROTOCOLS. 663 00:24:37,836 --> 00:24:39,938 I'M SPEAKING ON MY BEHALF 664 00:24:39,938 --> 00:24:42,374 TODAY, NOT ON ANY AGENCY OR MY 665 00:24:42,374 --> 00:24:44,376 EMPLOYER'S BEHALF. 666 00:24:44,376 --> 00:24:47,179 THIS IS THE CONVENTIONAL 667 00:24:47,179 --> 00:24:48,580 CONTINGENCY IN CRISIS FRAMEWORK 668 00:24:48,580 --> 00:24:51,149 WE USE WHEN WE THINK HOW A 669 00:24:51,149 --> 00:24:52,050 SURGE IS AFFECTING OUR CLINICAL 670 00:24:52,050 --> 00:24:53,952 CARE. 671 00:24:53,952 --> 00:24:57,522 IN CONVENTION IT'S USUAL STUFF. 672 00:24:57,522 --> 00:24:59,157 CONTINGENCY THEY DON'T POSE 673 00:24:59,157 --> 00:25:00,058 SUBSTANTIAL RISK OF OUTCOME TO 674 00:25:00,058 --> 00:25:01,693 A PATIENT. 675 00:25:01,693 --> 00:25:03,595 CRISIS WE ARE CROSSING A 676 00:25:03,595 --> 00:25:04,663 BOUNDARY WHERE THERE IS 677 00:25:04,663 --> 00:25:06,131 SUBSTANTIAL RISK. 678 00:25:06,131 --> 00:25:07,566 THIS SOUNDS BLACK AND WHITE, 679 00:25:07,566 --> 00:25:09,668 LIKE WE SWITCH ON THE LIGHT AND 680 00:25:09,668 --> 00:25:11,470 WE GO TO CRISIS STANDARD OF 681 00:25:11,470 --> 00:25:13,171 CARE PLANS. 682 00:25:13,171 --> 00:25:14,806 WHAT COVID REALLY TOLD US WAS, 683 00:25:14,806 --> 00:25:18,110 IT'S NOT THAT CLEAR. 684 00:25:18,110 --> 00:25:18,777 THAT DISTINCTION IS FOGGY AT 685 00:25:18,777 --> 00:25:20,445 TIMES. 686 00:25:20,445 --> 00:25:23,248 A LOT OF CENTERS OF CARE FOR 687 00:25:23,248 --> 00:25:25,250 WORK WAS FOCUSED OF BINARY 688 00:25:25,250 --> 00:25:30,889 RESOURCES YOU CAN'T DIVIDE OR 689 00:25:30,889 --> 00:25:31,857 ALLOCATE IN NON VERSUS ZERO 690 00:25:31,857 --> 00:25:33,959 WAYS. 691 00:25:33,959 --> 00:25:37,229 SOFA SCORES WERE A CONTRIBUTOR 692 00:25:37,229 --> 00:25:38,196 TO THAT. 693 00:25:38,196 --> 00:25:40,065 IT ASSUMED IT WOULD BE A CLEAR 694 00:25:40,065 --> 00:25:41,466 POINT WHICH WE WOULD GO INTO 695 00:25:41,466 --> 00:25:42,901 CRISIS. 696 00:25:42,901 --> 00:25:47,839 IT RELIED A LOT ON TRIAGE TEAMS 697 00:25:47,839 --> 00:25:49,641 TO MAKE ALLOCATIONS OF THESE 698 00:25:49,641 --> 00:25:50,909 BINARY RESOURCES. 699 00:25:50,909 --> 00:25:53,411 AND ASSUMED WE COULD IMPLEMENT 700 00:25:53,411 --> 00:25:54,412 ETHICAL IDEALS JUSTLY. 701 00:25:54,412 --> 00:25:55,547 THAT TURNED OUT TO BE PROBABLY 702 00:25:55,547 --> 00:25:56,515 NOT TRUE. 703 00:25:56,515 --> 00:25:58,617 WE HAD TO MAKE COMPROMISES NO 704 00:25:58,617 --> 00:26:01,186 MATTER WHAT WE TRIED TO DO, 705 00:26:01,186 --> 00:26:03,021 DESPITE OUR BEST INTENTIONS. 706 00:26:03,021 --> 00:26:05,624 SO WE ARE PRESENTED ON ALMOST A 707 00:26:05,624 --> 00:26:06,758 DAILY BASIS WITH QUESTIONS 708 00:26:06,758 --> 00:26:08,894 ABOUT WHEN DO WE ACTUALLY CROSS 709 00:26:08,894 --> 00:26:10,962 THAT LINE INTO CRISIS. 710 00:26:10,962 --> 00:26:13,098 WAS THE ABSENCE OF, IN MANY 711 00:26:13,098 --> 00:26:18,136 CASES THE CHEMO THERAPEUTICS 712 00:26:18,136 --> 00:26:20,038 DEPENDENT ON PLATINUM, A LOT OF 713 00:26:20,038 --> 00:26:21,773 PATIENT IT'S WAS. 714 00:26:21,773 --> 00:26:25,977 THEY WEREN'T ABLE TO GET THEIR 715 00:26:25,977 --> 00:26:26,645 USUAL CANCER TREATMENTS BECAUSE 716 00:26:26,645 --> 00:26:28,580 OF THE LAGS. 717 00:26:28,580 --> 00:26:30,916 WHAT DO WE DO FROM A LEGAL 718 00:26:30,916 --> 00:26:33,351 PROTECTIONS AND REGULATORY AND 719 00:26:33,351 --> 00:26:34,786 OTHER STANDPOINT AND DEVELOPING 720 00:26:34,786 --> 00:26:36,354 CONSISTENT GUIDANCE. 721 00:26:36,354 --> 00:26:38,657 DRUG SHORTAGE WAS SO PERVASIVE 722 00:26:38,657 --> 00:26:41,326 FOR ME, EVERY MONDAY I GET A 723 00:26:41,326 --> 00:26:42,961 COLOR CODED CHART THAT SHOWS 724 00:26:42,961 --> 00:26:43,929 WHICH OF THE DRUGS ARE IN 725 00:26:43,929 --> 00:26:45,096 SHORTAGE. 726 00:26:45,096 --> 00:26:46,498 IT BECOMES PART OF THE ROUTINE 727 00:26:46,498 --> 00:26:48,867 BUT WE HAVE TO BE CAREFUL TO 728 00:26:48,867 --> 00:26:50,268 THINK THROUGH THOSE RISKS, THAT 729 00:26:50,268 --> 00:26:51,937 REALLY IS POSING A RISK IN A 730 00:26:51,937 --> 00:26:56,141 LOT OF SITUATIONS TO PATIENTS. 731 00:26:56,141 --> 00:26:57,075 P.P.E. SHORTAGE, STAFFING 732 00:26:57,075 --> 00:26:58,476 SHORTAGES POSED QUESTIONS ABOUT 733 00:26:58,476 --> 00:27:00,845 CRISIS CENTERS OF CARE FOR 734 00:27:00,845 --> 00:27:02,948 CAREGIVERS, AT WHAT POINT DO WE 735 00:27:02,948 --> 00:27:05,050 PUT CAREGIVERS AT SUBSTANTIAL 736 00:27:05,050 --> 00:27:05,984 RISK AT THE BEDSIDE. 737 00:27:05,984 --> 00:27:08,386 I THINK WE NEED TO THINK MORE 738 00:27:08,386 --> 00:27:09,955 OF CRISIS STANDARD OF CARE AS A 739 00:27:09,955 --> 00:27:12,123 TOOLBOX. 740 00:27:12,123 --> 00:27:13,992 USING CLINICAL TOOLS, LEGAL AND 741 00:27:13,992 --> 00:27:15,427 REGULATORY FRAMEWORKS AND OTHER 742 00:27:15,427 --> 00:27:16,628 THINGS TO BEST ADAPT TO THE 743 00:27:16,628 --> 00:27:19,130 CIRCUMSTANCES AT HAND. 744 00:27:19,130 --> 00:27:21,933 THOSE CIRCUMSTANCES VERY, VERY 745 00:27:21,933 --> 00:27:24,035 RARELY AS SAMEER SAID INCLUDE A 746 00:27:24,035 --> 00:27:26,104 TRIAGE OF VEPT LATORS. 747 00:27:26,104 --> 00:27:30,508 OR VENTILATORS. 748 00:27:30,508 --> 00:27:32,811 LIKE CIRCUIT BREAKERS WE WANT 749 00:27:32,811 --> 00:27:33,678 THE SYSTEM TO GRACEFULLY 750 00:27:33,678 --> 00:27:34,479 DEGRADE. 751 00:27:34,479 --> 00:27:36,715 WE DON'T WANT THE SYSTEM TO 752 00:27:36,715 --> 00:27:37,949 JUST STOP PROVIDING CARE. 753 00:27:37,949 --> 00:27:40,051 WE WANT TO HAVE PROGRAMMED 754 00:27:40,051 --> 00:27:41,686 ADAPTATIONS ALONG THE WAY THAT 755 00:27:41,686 --> 00:27:44,656 MINIMIZE THE RISK ACROSS THAT 756 00:27:44,656 --> 00:27:46,491 SPECTRUM TO THE CARE PROVIDER 757 00:27:46,491 --> 00:27:48,660 AS WELL AS TO THE PATIENTS. 758 00:27:48,660 --> 00:27:51,730 SOME KEY ISSUES THAT CAME UP 759 00:27:51,730 --> 00:27:53,865 DURING COVID-19, THE MORAL 760 00:27:53,865 --> 00:27:55,734 DISTRESS AND ISSUES THAT WERE 761 00:27:55,734 --> 00:27:58,703 RISING AT THE BEDSIDE WITH 762 00:27:58,703 --> 00:28:00,639 ALLOCATION OF RESOURCES WEREN'T 763 00:28:00,639 --> 00:28:01,706 PERCEIVED OR SHARED AT THE 764 00:28:01,706 --> 00:28:03,475 CORPORATE LEVELS. 765 00:28:03,475 --> 00:28:07,679 THE CEO'S AND OTHERS, I THINK, 766 00:28:07,679 --> 00:28:10,582 DIDN'T WANT TO WILLFULLY 767 00:28:10,582 --> 00:28:11,716 PORTRAY THE BEDSIDE CLINICIANS 768 00:28:11,716 --> 00:28:13,485 BEING OUT OF TOUCH. 769 00:28:13,485 --> 00:28:16,855 BUT THERE WAS SUCH A PRESSURE 770 00:28:16,855 --> 00:28:17,689 TO MAINTAIN PROCEDURES BECAUSE 771 00:28:17,689 --> 00:28:19,858 OF THE DURATION OF THE EVENT, 772 00:28:19,858 --> 00:28:21,259 THE ABILITY TO RECOGNIZE CRISIS 773 00:28:21,259 --> 00:28:24,029 AND SAY WE WERE IN THAT KNOWING 774 00:28:24,029 --> 00:28:26,798 THAT MIGHT TRIGGER FURTHER 775 00:28:26,798 --> 00:28:29,000 RESTRICTIONS ON SURGERIES AND 776 00:28:29,000 --> 00:28:30,869 ELECTIVE PROCEDURES WAS A HILL 777 00:28:30,869 --> 00:28:32,737 NO ONE WAS WILLING TO MOUNT. 778 00:28:32,737 --> 00:28:35,974 BUT IT DID LEAD TO A REALLY 779 00:28:35,974 --> 00:28:37,409 SIGNIFICANT DISCREPANCY AND 780 00:28:37,409 --> 00:28:40,045 WHAT IT WAS AT THE BEDSIDE 781 00:28:40,045 --> 00:28:41,079 VERSUS BOARD ROOM. 782 00:28:41,079 --> 00:28:43,214 WE SAW A LOT OF ACCESS TO CARE 783 00:28:43,214 --> 00:28:43,915 ISSUES. 784 00:28:43,915 --> 00:28:46,217 EARLY ON IN THE URBAN AREAS, 785 00:28:46,217 --> 00:28:52,223 HOSPITALS IN NEW YORK CITY, 786 00:28:52,223 --> 00:28:53,992 LIKE ELMHURST. 787 00:28:53,992 --> 00:28:55,427 SURGE WAS HIGHER THAN OTHER 788 00:28:55,427 --> 00:28:56,828 HOSPITALS IN THE AREA. 789 00:28:56,828 --> 00:28:59,164 LATER ON IN THE PANDEMIC, WE 790 00:28:59,164 --> 00:29:00,799 SAW RURAL FACILITIES NO MATTER 791 00:29:00,799 --> 00:29:07,038 WHAT THEY TRIED COULD NOT GET 792 00:29:07,038 --> 00:29:13,144 TERTIARY CENTERS TO ACCEPT 793 00:29:13,144 --> 00:29:14,546 PATIENTS, HIGH POTASSIUM LEVELS 794 00:29:14,546 --> 00:29:16,381 FROM LACK OF DIALYSIS. 795 00:29:16,381 --> 00:29:18,149 A LOT OF AD HOC DECISIONS WERE 796 00:29:18,149 --> 00:29:18,950 MADE. 797 00:29:18,950 --> 00:29:20,852 WE HAD A SURVEY OF CLINICIANS 798 00:29:20,852 --> 00:29:23,455 IN MINNESOTA AND SOME OF THE 799 00:29:23,455 --> 00:29:25,256 MOST POIGNANT CAME FROM RURAL 800 00:29:25,256 --> 00:29:26,224 FACILITIES. 801 00:29:26,224 --> 00:29:28,827 I WAKE UP AT 4:00 EVERY 802 00:29:28,827 --> 00:29:31,863 MORNING, I'M NOT SURE I HAVE 803 00:29:31,863 --> 00:29:34,366 THE ENERGY TO TALK TO A FAMILY 804 00:29:34,366 --> 00:29:36,201 TO MAKE THEIR PATIENT D.N.R. 805 00:29:36,201 --> 00:29:37,869 BECAUSE WE DON'T HAVE THE 806 00:29:37,869 --> 00:29:38,136 RESOURCES. 807 00:29:38,136 --> 00:29:40,438 IT'S NOT SOMETHING WE SHOULD 808 00:29:40,438 --> 00:29:43,041 PUT ON THE FAMILIES OR 809 00:29:43,041 --> 00:29:43,975 CLINICIANS AT THE BEDSIDE. 810 00:29:43,975 --> 00:29:47,679 BUT THERE WAS A FAILURE ACROSS 811 00:29:47,679 --> 00:29:48,747 THE URBAN HOSPITALS, EVEN 812 00:29:48,747 --> 00:29:50,014 WITHIN HOSPITALS, A LOT OF 813 00:29:50,014 --> 00:29:51,416 TIMES IT SEEMED THE RISK WE 814 00:29:51,416 --> 00:29:53,985 WERE RUNNING IN THE EMERGENCY 815 00:29:53,985 --> 00:29:55,186 DEPARTMENT WAS SUBSTANTIALLY 816 00:29:55,186 --> 00:29:57,288 DIFFERENT THAN WHAT THE RISK 817 00:29:57,288 --> 00:29:58,790 WAS UPSTAIRS BECAUSE THEY COULD 818 00:29:58,790 --> 00:30:00,091 CONTROL THE FLOW AND WE COULD 819 00:30:00,091 --> 00:30:00,859 NOT. 820 00:30:00,859 --> 00:30:04,095 ALSO I THINK WE NEED TO THINK 821 00:30:04,095 --> 00:30:05,964 CAREFULLY ABOUT WHAT ASPECTS OF 822 00:30:05,964 --> 00:30:07,532 CRISIS CARE PLANS ARE SEPARATE 823 00:30:07,532 --> 00:30:08,767 FROM DAILY PLANS. 824 00:30:08,767 --> 00:30:10,101 INTEGRATION OF THOSE I THINK IS 825 00:30:10,101 --> 00:30:10,869 REALLY IMPORTANT. 826 00:30:10,869 --> 00:30:12,737 WHAT DO YOU DO WHEN YOU COME UP 827 00:30:12,737 --> 00:30:17,976 WITH A REALLY NICE PROCESS. 828 00:30:17,976 --> 00:30:23,448 DISTRIBUTION OF MONOCLONAL 829 00:30:23,448 --> 00:30:24,482 ANTIBODIES. 830 00:30:24,482 --> 00:30:25,517 ONE STATE SAID THEY WEREN'T 831 00:30:25,517 --> 00:30:27,986 GOING TO PARTICIPATE. 832 00:30:27,986 --> 00:30:29,621 MAINTAINING ACCESS AND EQUITY 833 00:30:29,621 --> 00:30:31,055 WHEN SOME SYSTEMS ARE OPTING 834 00:30:31,055 --> 00:30:32,424 OUT AND THERE'S NO REGULATORY 835 00:30:32,424 --> 00:30:34,058 OR LEGAL WAY TO FORCE THEM TO 836 00:30:34,058 --> 00:30:35,927 PARTICIPATE. 837 00:30:35,927 --> 00:30:38,963 TRIAGE TEAMS IN THE END I THINK 838 00:30:38,963 --> 00:30:40,165 PROVED PRETTY CUMBERSOME AND 839 00:30:40,165 --> 00:30:41,199 NOT NEEDED FOR MOST OF THE 840 00:30:41,199 --> 00:30:42,267 DECISIONS MADE. 841 00:30:42,267 --> 00:30:44,803 SO HOW DO WE ADAPT THAT INTO 842 00:30:44,803 --> 00:30:45,970 FUTURE ITERATIONS OF OUR CRISIS 843 00:30:45,970 --> 00:30:48,573 PLANNING? 844 00:30:48,573 --> 00:30:51,342 AS SAMEER MENTIONED SOFA WAS 845 00:30:51,342 --> 00:30:52,777 VALIDATED IN A MULTI-ORGAN 846 00:30:52,777 --> 00:30:57,048 FAILURE COHORT, BUT IT DOESN'T 847 00:30:57,048 --> 00:30:57,649 IDENTIFY WELL IN RESPIRATORY 848 00:30:57,649 --> 00:31:07,425 FAILURE. 849 00:31:07,425 --> 00:31:10,662 MANY HAVE ACUTE RENAL 850 00:31:10,662 --> 00:31:10,995 INSUFFICIENT. 851 00:31:10,995 --> 00:31:11,696 AND EVERYONE THOUGHT THEY WERE 852 00:31:11,696 --> 00:31:12,997 SPECIAL. 853 00:31:12,997 --> 00:31:14,632 THIS WAS SOMETHING WE RAN 854 00:31:14,632 --> 00:31:18,603 ACROSS AT THE STATE LEVEL, 855 00:31:18,603 --> 00:31:20,171 WHETHER MONOCLONAL OR VACCINES, 856 00:31:20,171 --> 00:31:22,540 EVERY GROUP FELT THEY SHOULD 857 00:31:22,540 --> 00:31:24,175 HAVE SPECIAL QUALIFICATIONS OR 858 00:31:24,175 --> 00:31:26,478 SPECIAL ACCESS TO SERVICES. 859 00:31:26,478 --> 00:31:28,913 YOU KNOW, TRYING TO DEFINE IN 860 00:31:28,913 --> 00:31:31,182 ADVANCE OF AN EVENT NEXT TIME 861 00:31:31,182 --> 00:31:34,385 WHO SHOULD QUALIFY FOR SPECIAL 862 00:31:34,385 --> 00:31:35,553 ACCESS, VERSUS NOT, I THINK 863 00:31:35,553 --> 00:31:38,089 WILL BE VERY IMPORTANT IN 864 00:31:38,089 --> 00:31:39,724 MANAGING SOME OF THAT NOISE. 865 00:31:39,724 --> 00:31:42,794 SO I REALLY WANT TO FOCUS A LOT 866 00:31:42,794 --> 00:31:43,995 OF OUR EFFORTS GOING FORWARD 867 00:31:43,995 --> 00:31:46,331 AVOIDING CRISIS. 868 00:31:46,331 --> 00:31:47,265 AS SAMEER MENTIONED LOAD 869 00:31:47,265 --> 00:31:50,935 BALANCING IS ONE OF THOSE KEY 870 00:31:50,935 --> 00:31:51,903 THINGS, REGIONAL CONSTRUCTS FOR 871 00:31:51,903 --> 00:31:55,773 SHARING WE ARE TRYING TO DO THE 872 00:31:55,773 --> 00:31:57,242 SAME CLINICAL ADAPTATION AND 873 00:31:57,242 --> 00:31:57,675 ANTICIPATING BETTER. 874 00:31:57,675 --> 00:32:00,945 AT THE END OF THE DAY YOU CAN 875 00:32:00,945 --> 00:32:02,380 DO THREE THINGS, BRING A 876 00:32:02,380 --> 00:32:04,716 RESOURCE IN, MOVE A PATIENT OUT 877 00:32:04,716 --> 00:32:05,483 OR TRIAGE THE RESOURCES YOU 878 00:32:05,483 --> 00:32:06,351 HAVE. 879 00:32:06,351 --> 00:32:07,986 WE DON'T WANT TO GET TO THE 880 00:32:07,986 --> 00:32:09,521 LAST POINT VERY OFTEN. 881 00:32:09,521 --> 00:32:10,788 THIS IS DATA FROM NEW YORK. 882 00:32:10,788 --> 00:32:12,657 WHEN NEW YORK CITY WAS 883 00:32:12,657 --> 00:32:13,591 PARTICULARLY OVERWHELMED, YOU 884 00:32:13,591 --> 00:32:17,562 COULD SEE THIS AREA OF VERY 885 00:32:17,562 --> 00:32:20,832 BRIGHT YELLOW HERE, OVER 90% OF 886 00:32:20,832 --> 00:32:22,233 AVERAGE I.C.U. OCCUPANCY. 887 00:32:22,233 --> 00:32:24,102 EVEN AROUND THAT, UP IN 888 00:32:24,102 --> 00:32:30,575 CONNECTICUT AND OTHER AREAS 889 00:32:30,575 --> 00:32:31,743 THERE WERE TERTIARY CENTERS 890 00:32:31,743 --> 00:32:32,977 CLOSE BY AND WE WEREN'T USING 891 00:32:32,977 --> 00:32:34,579 THEM. 892 00:32:34,579 --> 00:32:36,180 IT'S TO FULLY UTILIZE THE 893 00:32:36,180 --> 00:32:37,849 RESOURCES WITHIN A GIVEN AREA. 894 00:32:37,849 --> 00:32:39,951 WE TRIED TO DO THAT IN 895 00:32:39,951 --> 00:32:41,753 MINNESOTA, THROUGH THE CRITICAL 896 00:32:41,753 --> 00:32:43,121 CARE COORDINATION CENTER. 897 00:32:43,121 --> 00:32:45,590 AS YOU CAN SEE, WE TOOK ABOUT 898 00:32:45,590 --> 00:32:46,991 5,000 REQUESTS FOR TRANSFERS. 899 00:32:46,991 --> 00:32:49,060 WE WERE ABLE TO PLACE 1800 900 00:32:49,060 --> 00:32:49,794 PATIENTS. 901 00:32:49,794 --> 00:32:52,096 I THINK WE DID A GOOD JOB 902 00:32:52,096 --> 00:32:53,298 CONSIDERING THE RESOURCES WE 903 00:32:53,298 --> 00:32:54,699 HAD AVAILABLE. 904 00:32:54,699 --> 00:33:00,972 AND THIS WAS PUBLISHED, YOU 905 00:33:00,972 --> 00:33:03,041 COULD SEE IN THE METRO THERE 906 00:33:03,041 --> 00:33:05,376 WERE A LOT OF TRANSFERS BUT 907 00:33:05,376 --> 00:33:06,811 SOME OF THE MOST REMOTE 908 00:33:06,811 --> 00:33:08,913 HOSPITALS LIKE THE ONE ON 909 00:33:08,913 --> 00:33:09,614 CANADIAN BORDER INTERNATIONAL 910 00:33:09,614 --> 00:33:11,950 FALLS, SOME OF THE PLACE THAT'S 911 00:33:11,950 --> 00:33:14,519 TRANSFERRED THE MOST CRITICALLY 912 00:33:14,519 --> 00:33:15,987 ILL PATIENTS INTO OUR TERTIARY 913 00:33:15,987 --> 00:33:17,322 CENTERS. 914 00:33:17,322 --> 00:33:19,857 MAKING SURE THE NEEDS GET MET 915 00:33:19,857 --> 00:33:21,626 THROUGH SYSTEMS LIKE THIS, 916 00:33:21,626 --> 00:33:23,528 THROUGH OUR C-4, SO WE CAN MOVE 917 00:33:23,528 --> 00:33:25,263 THE RIGHT PATIENTS TO THE RIGHT 918 00:33:25,263 --> 00:33:27,165 PLACE AT THE RIGHT TIME IS HUGE. 919 00:33:27,165 --> 00:33:29,534 THAT HAS TO INVOLVE 920 00:33:29,534 --> 00:33:30,935 PRIORITIZATION, TO MAKE SURE 921 00:33:30,935 --> 00:33:32,303 THE PATIENTS WHO HAVE THE 922 00:33:32,303 --> 00:33:35,373 HIGHEST RISK OF DEATH OR 923 00:33:35,373 --> 00:33:36,975 CRITICALLY ILL OR PRIORITIZED 924 00:33:36,975 --> 00:33:38,376 FOR THE TERTIARY CENTERS BUT 925 00:33:38,376 --> 00:33:40,712 ALSO MAKE USE OF ALL OF THE 926 00:33:40,712 --> 00:33:41,913 I.C.U. BEDS IN THE STATE. 927 00:33:41,913 --> 00:33:44,482 WHEN I ASK HOSPITALS HOW MANY 928 00:33:44,482 --> 00:33:45,883 I.C.U. BEDS THEY HAVE, THEY MAY 929 00:33:45,883 --> 00:33:49,587 BE TALKING ABOUT A TELEBED, 930 00:33:49,587 --> 00:33:54,325 MONITORED BED, OR CAPABLE OF 931 00:33:54,325 --> 00:33:56,861 MECHANICAL VENTILATION BUT NOT 932 00:33:56,861 --> 00:33:59,697 DIALYSIS CAPABILITY. 933 00:33:59,697 --> 00:34:01,799 OR ECMO CAPABILITY. 934 00:34:01,799 --> 00:34:03,167 HOW DO WE MAXIMIZE USE OF ALL 935 00:34:03,167 --> 00:34:05,970 OF THOSE AND MAKE SURE PATIENTS 936 00:34:05,970 --> 00:34:08,740 WHO SIMPLY NEED MECHANICAL 937 00:34:08,740 --> 00:34:12,510 VENTILATION CAN BE CARED FOR IN 938 00:34:12,510 --> 00:34:15,446 AN URBAN HOSPITAL, WHILE 939 00:34:15,446 --> 00:34:17,715 PRESERVING TERTIARY FOR THE 940 00:34:17,715 --> 00:34:19,150 MOST ILL AND MOST COMPLEX. 941 00:34:19,150 --> 00:34:20,918 WE HAVE TO THINK OF TRIAGE A 942 00:34:20,918 --> 00:34:22,620 LITTLE DIFFERENTLY. 943 00:34:22,620 --> 00:34:24,989 EVERYBODY GETS UPSET ABOUT THE 944 00:34:24,989 --> 00:34:27,291 IDEA OF EXPLICIT TRIAGE WHEN WE 945 00:34:27,291 --> 00:34:28,226 SAY THIS PERSON PROBABLY 946 00:34:28,226 --> 00:34:29,427 SHOULDN'T BE RECEIVING THE 947 00:34:29,427 --> 00:34:30,561 RESOURCES THEY ARE RECEIVING AT 948 00:34:30,561 --> 00:34:31,696 THIS POINT. 949 00:34:31,696 --> 00:34:35,733 THE TRADE OFF WE RELY ON 950 00:34:35,733 --> 00:34:38,736 IMPLICIT TRIAGE, AD HOC AT THE 951 00:34:38,736 --> 00:34:40,138 BEDSIDE BY A PROVIDER. 952 00:34:40,138 --> 00:34:41,572 THERE ARE OTHER BIASES THAT 953 00:34:41,572 --> 00:34:42,707 CREEP INTO THOSE DECISIONS WE 954 00:34:42,707 --> 00:34:45,276 WANT TO TRY OUR BEST TO 955 00:34:45,276 --> 00:34:45,543 ELIMINATE. 956 00:34:45,543 --> 00:34:47,378 ACCESS TRIAGE AS WE MENTIONED, 957 00:34:47,378 --> 00:34:48,613 CAN YOU ACCESS THE SERVICES YOU 958 00:34:48,613 --> 00:34:49,747 NEED. 959 00:34:49,747 --> 00:34:52,083 THAT WAS A HUGE ISSUE DURING 960 00:34:52,083 --> 00:34:53,951 COVID AND HONESTLY CONTINUES TO 961 00:34:53,951 --> 00:34:56,154 BE AN ISSUE IN RURAL UNITED 962 00:34:56,154 --> 00:34:56,988 STATES, PARTICULARLY RIGHT NOW. 963 00:34:56,988 --> 00:34:59,991 WE ARE THINKING FOR THE MOST 964 00:34:59,991 --> 00:35:02,093 PART ABOUT TERTIARY TRIAGE, 965 00:35:02,093 --> 00:35:04,062 PROACTIVE TRIAGE AFTER WE HAVE 966 00:35:04,062 --> 00:35:05,563 STARTED DEFINITIVE TREATMENT. 967 00:35:05,563 --> 00:35:06,964 NOT TALKING ABOUT PRIMARY 968 00:35:06,964 --> 00:35:09,500 TRIAGE WHEN THEY FIRST HIT THE 969 00:35:09,500 --> 00:35:13,438 EMERGENCY DEPARTMENT AFTER A 970 00:35:13,438 --> 00:35:14,839 MASS CASUALTY INCIDENT OR AFTER 971 00:35:14,839 --> 00:35:16,507 A CT OR OTHER THINGS. 972 00:35:16,507 --> 00:35:18,810 WHEN DO WE ASSESS THE PATIENT 973 00:35:18,810 --> 00:35:20,912 AND DETERMINE WE CAN'T CONTINUE 974 00:35:20,912 --> 00:35:22,780 TO PROVIDE THE RESOURCES? 975 00:35:22,780 --> 00:35:23,948 WHEN WE MAKE DECISIONS LIKE 976 00:35:23,948 --> 00:35:26,784 THIS, THE OFFICE OF CIVIL 977 00:35:26,784 --> 00:35:28,853 RIGHTS HAS BASICALLY INSTRUCTED 978 00:35:28,853 --> 00:35:29,487 AN INDIVIDUALIZED PATIENT 979 00:35:29,487 --> 00:35:31,222 ASSESSMENT BE DONE. 980 00:35:31,222 --> 00:35:33,091 WE SHOULDN'T BE CONSIDERING AGE 981 00:35:33,091 --> 00:35:35,393 AS AN INDEPENDENT OR GENERAL 982 00:35:35,393 --> 00:35:38,196 FACTOR, RACE, WE SHOULD BE 983 00:35:38,196 --> 00:35:40,031 CONCERNING THE DIAGNOSIS, 984 00:35:40,031 --> 00:35:40,898 UNDERLYING DISEASE STATES. 985 00:35:40,898 --> 00:35:44,268 WHAT IT MEANS TO THAT PATIENT 986 00:35:44,268 --> 00:35:45,903 AS AN INDIVIDUAL AND WHAT IS 987 00:35:45,903 --> 00:35:47,338 THE CHANCE OF BENEFIT FROM THE 988 00:35:47,338 --> 00:35:48,406 SERVICES WE WOULD LIKE TO TRY 989 00:35:48,406 --> 00:35:49,874 TO PROVIDE. 990 00:35:49,874 --> 00:35:52,009 IN THE PAST WE THOUGHT ABOUT 991 00:35:52,009 --> 00:35:53,611 THIS FROM WHO BENEFITS MOST, I 992 00:35:53,611 --> 00:35:55,780 THINK WE NEED TO REORIENTED WHO 993 00:35:55,780 --> 00:35:57,482 SUFFERS THE LEAST WHEN WE DON'T 994 00:35:57,482 --> 00:35:59,684 OFFER A THERAPY. 995 00:35:59,684 --> 00:36:00,818 WHO IS RECEIVING NON-BENEFICIAL 996 00:36:00,818 --> 00:36:02,253 TREATMENTS RIGHT NOW. 997 00:36:02,253 --> 00:36:04,789 BECAUSE ALL OF US COULD 998 00:36:04,789 --> 00:36:06,924 PROBABLY GO THROUGH I.C.U.'S 999 00:36:06,924 --> 00:36:08,092 AND IDENTIFY PATIENTS WHO DON'T 1000 00:36:08,092 --> 00:36:09,260 HAVE A REASONABLE CHANCE MAKING 1001 00:36:09,260 --> 00:36:10,995 IT OUT OF THAT INTENSIVE CARE 1002 00:36:10,995 --> 00:36:12,296 UNIT. 1003 00:36:12,296 --> 00:36:14,899 THERE'S AN AWFUL LOT OF 1004 00:36:14,899 --> 00:36:16,601 POTENTIAL SOCIAL FACTORS 1005 00:36:16,601 --> 00:36:18,069 PROPOSED BEING INCLUDED IN 1006 00:36:18,069 --> 00:36:19,437 TRIAGE ALGORITHMS. 1007 00:36:19,437 --> 00:36:23,908 WE NEED TO BE EXTRAORDINARILY 1008 00:36:23,908 --> 00:36:25,243 CAREFUL ABOUT DOING THAT. 1009 00:36:25,243 --> 00:36:27,211 I DON'T HAVE THE TIME TO GO 1010 00:36:27,211 --> 00:36:28,546 INTO DETAILS NOW. 1011 00:36:28,546 --> 00:36:32,583 WE NEED TO HONE OUR PROGNOSTIC 1012 00:36:32,583 --> 00:36:34,185 CAPABILITY FIRST AND THINK HOW 1013 00:36:34,185 --> 00:36:35,153 AND WHEN THOSE CONSIDERATIONS 1014 00:36:35,153 --> 00:36:37,688 COME IN AND MAKE SURE WE AS 1015 00:36:37,688 --> 00:36:39,824 CLINICIANS AREN'T TRYING TO 1016 00:36:39,824 --> 00:36:40,725 SOLVE POPULATION-BASED PROBLEMS 1017 00:36:40,725 --> 00:36:41,726 AT THE BEDSIDE. 1018 00:36:41,726 --> 00:36:43,594 THE NOT WHAT WE DO AND NOT WHAT 1019 00:36:43,594 --> 00:36:45,163 WE SHOULD BE DOING. 1020 00:36:45,163 --> 00:36:48,166 THE FOCUS NOT ON THE TRIAGE OR 1021 00:36:48,166 --> 00:36:49,567 VENTILATORS AS MUCH AS REGIONAL 1022 00:36:49,567 --> 00:36:50,501 CONSISTENCY. 1023 00:36:50,501 --> 00:36:52,270 ARE WE TRYING TO DO THE SAME 1024 00:36:52,270 --> 00:36:53,571 THING NO MATTER WHAT THE SIZE 1025 00:36:53,571 --> 00:36:55,706 OF THE HOSPITAL IS WITH THE 1026 00:36:55,706 --> 00:36:58,342 RESOURCES WE HAVE AVAILABLE. 1027 00:36:58,342 --> 00:36:59,944 THERE'S THREE BASIC PARTS OF 1028 00:36:59,944 --> 00:37:02,280 THE EQUATION THAT GO IN, EXCUSE 1029 00:37:02,280 --> 00:37:07,218 ME, I'M REALLY SORRY. 1030 00:37:07,218 --> 00:37:09,587 THERE'S THREE BASIC PARTS OF 1031 00:37:09,587 --> 00:37:10,221 THE EQUATION WHAT CONSTITUTES 1032 00:37:10,221 --> 00:37:11,889 CARE. 1033 00:37:11,889 --> 00:37:13,457 THE TIME WE SPEND DEVOTED TO 1034 00:37:13,457 --> 00:37:14,458 THE CARE. 1035 00:37:14,458 --> 00:37:16,327 THE AMOUNT OF TIME SOMEONE WILL 1036 00:37:16,327 --> 00:37:17,562 USE A RESOURCE LIKE A 1037 00:37:17,562 --> 00:37:20,898 VENTILATOR. 1038 00:37:20,898 --> 00:37:23,167 IT'S THE TREATER RESOURCES. 1039 00:37:23,167 --> 00:37:24,836 THE TREATMENT RESOURCES, THE 1040 00:37:24,836 --> 00:37:27,171 INTENSITY OF THE LEVEL OF 1041 00:37:27,171 --> 00:37:27,438 TREATMENT. 1042 00:37:27,438 --> 00:37:28,372 THE EXPERTISE, THE RESOURCES 1043 00:37:28,372 --> 00:37:29,040 AND AMOUNT OF TIME COME 1044 00:37:29,040 --> 00:37:30,208 TOGETHER. 1045 00:37:30,208 --> 00:37:32,543 THE MILITARY HAS DONE A REALLY 1046 00:37:32,543 --> 00:37:34,645 NICE JOB PARSING OUT SOME OF 1047 00:37:34,645 --> 00:37:36,280 THESE DISTINCTIONS I THINK WE 1048 00:37:36,280 --> 00:37:40,651 CAN CONTINUE TO GO FURTHER WITH. 1049 00:37:40,651 --> 00:37:41,953 THE TOURNIQUET THERE IS AN 1050 00:37:41,953 --> 00:37:43,554 EXAMPLE, WHAT IS THE OPTIMAL 1051 00:37:43,554 --> 00:37:43,788 BALANCE. 1052 00:37:43,788 --> 00:37:46,824 IF YOU WANT THE MINIMAL AMOUNT 1053 00:37:46,824 --> 00:37:57,301 OF TIME, MINIMAL AMOUNT OF 1054 00:37:58,302 --> 00:37:59,904 TREATMENT, MAXIMUM BENEFIT. 1055 00:37:59,904 --> 00:38:01,539 AT THE PROVIDER LEVEL, I DON'T 1056 00:38:01,539 --> 00:38:02,940 EXPECT YOU TO READ THIS 1057 00:38:02,940 --> 00:38:05,743 GRAPHIC, BUT THE A FIGURE TAKEN 1058 00:38:05,743 --> 00:38:07,845 FROM A JOURNAL, THE JOINT 1059 00:38:07,845 --> 00:38:12,183 COMMISSION THIS IS OPEN SOURCE, 1060 00:38:12,183 --> 00:38:13,284 CONSIDERATIONS AS THE DECISIONS 1061 00:38:13,284 --> 00:38:15,253 BECOME MORE WEIGHTY FOR THE 1062 00:38:15,253 --> 00:38:16,888 PATIENT, AS THEY AFFECT THEIR 1063 00:38:16,888 --> 00:38:19,423 OUTCOME MORE, WE SHOULD BE MUCH 1064 00:38:19,423 --> 00:38:22,026 MORE CAREFUL WITH THOSE. 1065 00:38:22,026 --> 00:38:23,694 EMPHASIZING CONSULTATIONS WHEN 1066 00:38:23,694 --> 00:38:24,595 IT'S OUTSIDE YOUR USUAL SCOPE 1067 00:38:24,595 --> 00:38:25,563 OF PRACTICE. 1068 00:38:25,563 --> 00:38:27,899 AND MAKING SURE WE DO HAVE A 1069 00:38:27,899 --> 00:38:31,168 TRIAGE TEAM OR NUMEROUS EYES ON 1070 00:38:31,168 --> 00:38:33,504 A DECISION REMOVING SOMEONE 1071 00:38:33,504 --> 00:38:34,438 FROM MECHANICAL VENTILATION 1072 00:38:34,438 --> 00:38:35,840 AGAINST THE WISHES OF 1073 00:38:35,840 --> 00:38:36,507 THEMSELVES OR AGAINST THE 1074 00:38:36,507 --> 00:38:38,175 FAMILY WISHES. 1075 00:38:38,175 --> 00:38:40,378 WE NEED TO ALSO MAKE SURE 1076 00:38:40,378 --> 00:38:41,879 PROVIDERS ARE SUPPORTED. 1077 00:38:41,879 --> 00:38:43,981 I SAW WAY TOO MANY INSTANCES 1078 00:38:43,981 --> 00:38:45,716 WHICH THE PROVIDERS WERE 1079 00:38:45,716 --> 00:38:48,286 SADDLED WITH DECISIONS AND 1080 00:38:48,286 --> 00:38:49,453 MORAL INJURY DURING COVID-19 I 1081 00:38:49,453 --> 00:38:51,355 DON'T EVER WANT TO SEE REPEATED. 1082 00:38:51,355 --> 00:38:53,624 THE CHANCE OF BURN OUT. 1083 00:38:53,624 --> 00:38:55,793 THE CHANCE OF MORAL DISTRESS IS 1084 00:38:55,793 --> 00:38:57,662 VERY, VERY HIGH IN THESE 1085 00:38:57,662 --> 00:38:58,829 CIRCUMSTANCES WHEN WE CAN'T 1086 00:38:58,829 --> 00:39:00,765 PRACTICE WE KNOW WE SHOULD BE 1087 00:39:00,765 --> 00:39:02,133 CAPABLE OF PRACTICES. 1088 00:39:02,133 --> 00:39:04,669 WE HAVE TO MAKE SURE OUR 1089 00:39:04,669 --> 00:39:05,569 PROVIDER SUPPORT IS BETTER NEXT 1090 00:39:05,569 --> 00:39:07,705 TIME AROUND. 1091 00:39:07,705 --> 00:39:09,106 LEGAL PROTECTIONS FOR PROVIDERS 1092 00:39:09,106 --> 00:39:10,441 ARE INCREDIBLY IMPORTANT. 1093 00:39:10,441 --> 00:39:11,342 I THINK AGAIN SOMETHING WE HAVE 1094 00:39:11,342 --> 00:39:13,144 TO BE ABLE TO DEMONSTRATE WE 1095 00:39:13,144 --> 00:39:17,081 ARE PUTTING OURSELVES IN LEGAL 1096 00:39:17,081 --> 00:39:18,716 JEOPARDY WHEN MAKING ANY OF 1097 00:39:18,716 --> 00:39:21,285 THESE DECISIONS OR PROVIDING 1098 00:39:21,285 --> 00:39:22,787 IN-PLACE CARE WE DON'T HAVE 1099 00:39:22,787 --> 00:39:24,088 DIRECT RESPONSIBILITY FOR. 1100 00:39:24,088 --> 00:39:26,190 THIS HAS COME UP NUMEROUS TIMES 1101 00:39:26,190 --> 00:39:28,059 AS AN EXAMPLE WHEN CRITICAL 1102 00:39:28,059 --> 00:39:30,161 CARE OR OTHER PROVIDERS ARE 1103 00:39:30,161 --> 00:39:31,796 VERY COMFORTABLE CONTINUING TO 1104 00:39:31,796 --> 00:39:33,931 PROVIDE ADVICE AND SUPPORT FOR 1105 00:39:33,931 --> 00:39:34,932 PATIENTS BEING PROVIDED FOR IN 1106 00:39:34,932 --> 00:39:36,000 A HOSPITAL THEY WON'T HAVE 1107 00:39:36,000 --> 00:39:38,602 RESPONSIBILITY FOR. 1108 00:39:38,602 --> 00:39:39,971 SO CRISIS CONDITIONS EXISTED IN 1109 00:39:39,971 --> 00:39:40,938 48 STATES. 1110 00:39:40,938 --> 00:39:43,541 I DON'T DOUBT THEY EXISTED IN 1111 00:39:43,541 --> 00:39:45,142 OREGON AND IOWA BUT WE COULDN'T 1112 00:39:45,142 --> 00:39:46,544 DOCUMENT THAT. 1113 00:39:46,544 --> 00:39:49,347 BUT OF THOSE STATES VERY FEW 1114 00:39:49,347 --> 00:39:51,015 IMPLEMENTED ANY LEGAL 1115 00:39:51,015 --> 00:39:52,183 STRATEGIES TO PROTECT PROVIDERS 1116 00:39:52,183 --> 00:39:54,018 THAT WERE MAKING DECISIONS. 1117 00:39:54,018 --> 00:39:56,087 SOME OF THOSE DID ENACT LEGAL 1118 00:39:56,087 --> 00:39:57,855 PROTECTIONS BUT SOME WERE ONLY 1119 00:39:57,855 --> 00:39:59,323 FOR COVID PATIENTS. 1120 00:39:59,323 --> 00:40:01,025 AND IN SOME CASES THOSE LEGAL 1121 00:40:01,025 --> 00:40:02,059 PROTECTIONS WERE PUT IN PLACE 1122 00:40:02,059 --> 00:40:04,095 AT THE START OF THE PANDEMIC 1123 00:40:04,095 --> 00:40:08,833 AND ESSENTIALLY PROVIDED ANY 1124 00:40:08,833 --> 00:40:10,768 PROVIDER DECISION, THAT'S 1125 00:40:10,768 --> 00:40:12,203 RISKY, THAT'S OVER BROAD AND WE 1126 00:40:12,203 --> 00:40:13,104 DON'T NEED THAT LEVEL OF 1127 00:40:13,104 --> 00:40:14,538 PROTECTION. 1128 00:40:14,538 --> 00:40:16,407 IF ANY OF OUR ALLOCATION 1129 00:40:16,407 --> 00:40:17,341 DECISIONS WILL BE SUCCESSFUL, 1130 00:40:17,341 --> 00:40:19,443 WHEN THEY GET DOWN TO 1131 00:40:19,443 --> 00:40:20,177 NON-BENEFICIAL TREATMENT, WE 1132 00:40:20,177 --> 00:40:25,616 WILL HAVE TO HAVE SOME DEGREE 1133 00:40:25,616 --> 00:40:28,452 OF IMMUNITY AND INDEMNIFICATION. 1134 00:40:28,452 --> 00:40:32,023 THERE WAS A HOSPITAL IN A 1135 00:40:32,023 --> 00:40:35,059 SUBURB A PATIENT WITH COVID 1136 00:40:35,059 --> 00:40:37,361 RELATED LUNG INJURY WHO WASN'T 1137 00:40:37,361 --> 00:40:39,964 GOING TO SURVIVE. 1138 00:40:39,964 --> 00:40:43,267 QUESTIONS TO SAY THIS PATIENT'S 1139 00:40:43,267 --> 00:40:46,070 CARE WAS FUTILE AND SUPPORTS 1140 00:40:46,070 --> 00:40:51,108 SHOULD BE WITHDRAWN, THE FAMILY 1141 00:40:51,108 --> 00:40:54,912 OBJECTED AND GOT A RESTRAINING 1142 00:40:54,912 --> 00:40:55,780 ORDER PREVENTING REMOVING THE 1143 00:40:55,780 --> 00:40:58,482 VENTILATOR. 1144 00:40:58,482 --> 00:41:00,084 ACROSS THE TIME THAT INDIVIDUAL 1145 00:41:00,084 --> 00:41:02,453 WAS IN THE I.C.U. AT MERCY, WE 1146 00:41:02,453 --> 00:41:04,088 HAD HUNDREDS OF PATIENTS WHO 1147 00:41:04,088 --> 00:41:05,356 COULD HAVE BENEFITED FROM THOSE 1148 00:41:05,356 --> 00:41:06,190 SERVICES. 1149 00:41:06,190 --> 00:41:07,591 IF WE ARE GOING TO DO THIS 1150 00:41:07,591 --> 00:41:09,660 RIGHT WE HAVE TO HAVE SOME 1151 00:41:09,660 --> 00:41:11,062 PROTECTION FOR THESE DECISIONS. 1152 00:41:11,062 --> 00:41:13,631 THIS IS JUST AN EXTREME 1153 00:41:13,631 --> 00:41:15,266 EXAMPLE, THIS PATIENT'S CARE 1154 00:41:15,266 --> 00:41:19,737 WAS CLEARLY FUTILE, HE WAS 1155 00:41:19,737 --> 00:41:20,871 FINALLY TRANSFERRED, THEY FOUND 1156 00:41:20,871 --> 00:41:23,474 A LOCATION TO ACCEPT HIM, HE 1157 00:41:23,474 --> 00:41:25,843 EXPIRED A FEW DAYS AFTER 1158 00:41:25,843 --> 00:41:26,210 ARRIVING THERE. 1159 00:41:26,210 --> 00:41:27,945 VERY UNFORTUNATE SITUATION. 1160 00:41:27,945 --> 00:41:29,814 FURTHER THE MORAL INJURY AND 1161 00:41:29,814 --> 00:41:31,749 DISTRESS EXPERIENCED BY THE 1162 00:41:31,749 --> 00:41:33,651 C.M.O. AND PROVIDERS OF THE 1163 00:41:33,651 --> 00:41:37,822 HOSPITAL WERE UNPRECEDENTED. 1164 00:41:37,822 --> 00:41:39,924 THEIR HOMES WERE VANDALIZING, 1165 00:41:39,924 --> 00:41:41,792 THE SOCIAL MEDIA CAMPAIGNS 1166 00:41:41,792 --> 00:41:43,427 AGAINST THEM WERE UNRELENTING, 1167 00:41:43,427 --> 00:41:45,062 FOR TRYING TO DO THE RIGHT 1168 00:41:45,062 --> 00:41:47,264 THING NOT ONLY FOR THIS PATIENT 1169 00:41:47,264 --> 00:41:48,566 BUT THE POPULATION. 1170 00:41:48,566 --> 00:41:53,604 LOOKING AT THE FOUR S'S, 1171 00:41:53,604 --> 00:41:55,573 SPECIAL CONSIDERATIONS AND 1172 00:41:55,573 --> 00:41:56,207 SUPPLIES. 1173 00:41:56,207 --> 00:41:58,776 DO WE HAVE THE RIGHT P.P.E. 1174 00:41:58,776 --> 00:42:02,379 THIS IS THE BASIS FOR LOOKING 1175 00:42:02,379 --> 00:42:04,281 AT CONTINGENCIES ACROSS THE 1176 00:42:04,281 --> 00:42:07,084 CONTINUUM OF CARE. 1177 00:42:07,084 --> 00:42:07,718 STATE OF MINNESOTA PUBLISHED 1178 00:42:07,718 --> 00:42:09,687 WHAT DO YOU DO IF YOU DON'T 1179 00:42:09,687 --> 00:42:11,188 HAVE ENOUGH OXYGEN. 1180 00:42:11,188 --> 00:42:13,357 THIS BECAME A VERY PRESSING 1181 00:42:13,357 --> 00:42:14,558 SITUATION IN HOSPITALS DURING 1182 00:42:14,558 --> 00:42:17,261 COVID BECAUSE OF THE HIGH FLOW 1183 00:42:17,261 --> 00:42:18,662 UTILITIES WE WERE USING. 1184 00:42:18,662 --> 00:42:21,031 TO THE POINT SOME HOSPITALS HAD 1185 00:42:21,031 --> 00:42:23,367 TO USE TEMPORARY OXYGEN 1186 00:42:23,367 --> 00:42:24,068 PROVISION PIPE, THROUGH 1187 00:42:24,068 --> 00:42:28,973 WINDOWS, THEY HAD TO HAVE 1188 00:42:28,973 --> 00:42:30,841 SPRINKLERS ON THE VAPORIZORS TO 1189 00:42:30,841 --> 00:42:33,177 KEEP THEM FROM ICING OVER. 1190 00:42:33,177 --> 00:42:36,947 IT'S NO SURPRISE WHEN YOU MAP 1191 00:42:36,947 --> 00:42:39,517 THAT S-DOMAIN AGAINST THE 1192 00:42:39,517 --> 00:42:41,152 DIAGRAM HERE THAT CMS USES TO 1193 00:42:41,152 --> 00:42:43,988 LOOK AT ROOT CAUSE ANALYSES FOR 1194 00:42:43,988 --> 00:42:45,156 POOR OUTCOMES, IT'S THE SAME 1195 00:42:45,156 --> 00:42:46,323 FACTORS. 1196 00:42:46,323 --> 00:42:47,992 SAMEER AND I HAVE REALLY 1197 00:42:47,992 --> 00:42:49,627 THOUGHT ABOUT THIS, IN CONTEXT 1198 00:42:49,627 --> 00:42:51,595 OF, THIS IS NOT A DISASTER 1199 00:42:51,595 --> 00:42:52,229 PROBLEM. 1200 00:42:52,229 --> 00:42:53,197 THIS IS A PATIENT SAFETY 1201 00:42:53,197 --> 00:42:56,834 PROBLEM. 1202 00:42:56,834 --> 00:42:58,202 DISASTERS UNMASK THE WEAKNESSES 1203 00:42:58,202 --> 00:43:00,070 IN OUR CARE DELIVERY SYSTEM AND 1204 00:43:00,070 --> 00:43:03,440 ALLOW US TO SEE WHERE THE 1205 00:43:03,440 --> 00:43:03,774 PROBLEMS ARE. 1206 00:43:03,774 --> 00:43:05,209 WE HAD A UNIQUE OPPORTUNITY TO 1207 00:43:05,209 --> 00:43:06,744 DO THAT WITH COVID AND WE HAVE 1208 00:43:06,744 --> 00:43:12,383 IT GOING FORWARD. 1209 00:43:12,383 --> 00:43:13,284 THE SCIENCE TERM, RELATIVELY 1210 00:43:13,284 --> 00:43:14,485 LIMITED. 1211 00:43:14,485 --> 00:43:15,519 BECAUSE EVEN THOUGH THESE 1212 00:43:15,519 --> 00:43:17,288 BUCKETS SEEM THEY ARE THE RIGHT 1213 00:43:17,288 --> 00:43:19,857 BUCKETS OF THE CARE AND OVERALL 1214 00:43:19,857 --> 00:43:21,492 SENSE THAT IS DELIVERED, WE 1215 00:43:21,492 --> 00:43:22,359 DON'T YET UNDERSTAND WHERE THE 1216 00:43:22,359 --> 00:43:25,029 RISKS ARE. 1217 00:43:25,029 --> 00:43:28,299 SO BACK YEARS AGO WHEN WE WERE 1218 00:43:28,299 --> 00:43:31,302 LOOKING AT CARDIAC ARREST, THE 1219 00:43:31,302 --> 00:43:31,969 EPSTEIN CONSENSUS CONFERENCE 1220 00:43:31,969 --> 00:43:34,405 WHAT'S PUT TOGETHER IN NORWAY. 1221 00:43:34,405 --> 00:43:35,573 THEY BASICALLY CAME OUT WITH 1222 00:43:35,573 --> 00:43:38,108 THIS IS HOW WE WILL DEFINE THE 1223 00:43:38,108 --> 00:43:39,476 TIME INTERVALS, THESE ARE THE 1224 00:43:39,476 --> 00:43:40,811 DEFINITIONS WE WILL APPLY TO 1225 00:43:40,811 --> 00:43:41,712 CARDIAC ARREST. 1226 00:43:41,712 --> 00:43:43,447 THIS IS THE CHAIN OF SURVIVAL 1227 00:43:43,447 --> 00:43:44,882 WE WILL SEE BETWEEN THE 1228 00:43:44,882 --> 00:43:46,750 APPLICATION OF SCIENCE, THE 1229 00:43:46,750 --> 00:43:47,484 EDUCATION, THE LOCAL 1230 00:43:47,484 --> 00:43:50,988 IMPLEMENTATION OF THOSE THINGS 1231 00:43:50,988 --> 00:43:51,388 EQUALING SURVIVAL. 1232 00:43:51,388 --> 00:43:52,556 I THINK IT'S EXACTLY THE SAME 1233 00:43:52,556 --> 00:43:54,658 KIND OF THINK WE NEED TO THINK 1234 00:43:54,658 --> 00:43:56,093 ABOUT APPLYING TO THE SCIENCE 1235 00:43:56,093 --> 00:43:59,330 OF SURGE, AS WE TRY TO PLUG THE 1236 00:43:59,330 --> 00:44:02,099 HOLES IN THE SWISS CHEESE, 1237 00:44:02,099 --> 00:44:03,434 SYSTEMS FAILURE THAT LEADS TO 1238 00:44:03,434 --> 00:44:05,402 POOR OUTCOMES. 1239 00:44:05,402 --> 00:44:06,337 BUT IDENTIFYING THOSE PROBLEMS 1240 00:44:06,337 --> 00:44:09,106 IS THE NEXT STEP THAT SAMEER'S 1241 00:44:09,106 --> 00:44:11,709 DATA AND OTHERS LEADS US TO. 1242 00:44:11,709 --> 00:44:12,610 WHAT GOING FORWARD DO WE WANT 1243 00:44:12,610 --> 00:44:14,478 TO KNOW. 1244 00:44:14,478 --> 00:44:18,015 AND WHAT AS RESEARCHERS AND 1245 00:44:18,015 --> 00:44:19,149 CLINICIANS CONTRIBUTE TO 1246 00:44:19,149 --> 00:44:19,883 IMPROVEMENT IN THESE 1247 00:44:19,883 --> 00:44:21,285 PROCESSESMENT WITHIN A HOSPITAL 1248 00:44:21,285 --> 00:44:22,553 YOU HAVE A FINITE AMOUNT OF 1249 00:44:22,553 --> 00:44:23,654 SPACE. 1250 00:44:23,654 --> 00:44:25,356 BASED ON THE LOADS AND THE 1251 00:44:25,356 --> 00:44:26,457 SPACE AVAILABLE, WHAT ARE THE 1252 00:44:26,457 --> 00:44:28,592 BEST PLACES TO PUT PEOPLE? 1253 00:44:28,592 --> 00:44:30,928 WHO ARE THE BEST CARE 1254 00:44:30,928 --> 00:44:32,796 DELIVERERS, YOU KNOW, FROM A 1255 00:44:32,796 --> 00:44:35,366 TRAINING STANDPOINT, FROM A 1256 00:44:35,366 --> 00:44:37,001 HIERARCHY OF CARE STANDPOINT. 1257 00:44:37,001 --> 00:44:40,070 WHEN WE DELIVER CARE USING 1258 00:44:40,070 --> 00:44:40,738 NON-TRADITIONAL STAFFING MODELS 1259 00:44:40,738 --> 00:44:41,939 WHAT DOES THAT MEAN? 1260 00:44:41,939 --> 00:44:45,042 IS IT BETTER TO DO THAT OR 1261 00:44:45,042 --> 00:44:47,478 LENGTHEN. 1262 00:44:47,478 --> 00:44:54,251 WHAT IMPLICATIONS DOES FATIGUE 1263 00:44:54,251 --> 00:44:56,854 HAVE TO COGNITIVE LOAD. 1264 00:44:56,854 --> 00:44:59,623 SOME MAY VARY BY TIME OF DAY, I 1265 00:44:59,623 --> 00:45:01,525 WORK STRAIGHT NIGHT SHIFTS, I 1266 00:45:01,525 --> 00:45:02,726 KNOW COGNITIVELY I'M NOT THE 1267 00:45:02,726 --> 00:45:04,495 SAME AS NIGHT AS I AM DURING 1268 00:45:04,495 --> 00:45:07,131 THE DAY. 1269 00:45:07,131 --> 00:45:08,332 THE E.H.R.'S ARE FULL OF DATA 1270 00:45:08,332 --> 00:45:09,733 RIGHT NOW. 1271 00:45:09,733 --> 00:45:11,602 WE HAVE NO SHORTAGE OF DATA BUT 1272 00:45:11,602 --> 00:45:13,237 WE HAVE A SHORTAGE OF 1273 00:45:13,237 --> 00:45:14,872 APPLICATION SCHEMES WE CAN TAKE 1274 00:45:14,872 --> 00:45:17,441 AND TRY TO APPLY TO THAT AND 1275 00:45:17,441 --> 00:45:19,576 MAKE MEANINGFUL ANALYSES AND 1276 00:45:19,576 --> 00:45:20,744 LEAD TO MEANINGFUL OUTCOMES. 1277 00:45:20,744 --> 00:45:23,113 BUT THE DATA IS OMNI PRESENT. 1278 00:45:23,113 --> 00:45:26,583 THE AMOUNT OF DATA FED BY 1279 00:45:26,583 --> 00:45:28,218 E.H.R.'S INTO DIGITAL LAKES 1280 00:45:28,218 --> 00:45:31,488 RIGHT NOW FOR MULTIPLE VARIED 1281 00:45:31,488 --> 00:45:37,061 PURPOSES, UNFORTUNATELY NONE OF 1282 00:45:37,061 --> 00:45:39,196 THEM ALLOW RESPONSE BY A.I. 1283 00:45:39,196 --> 00:45:41,498 DRIVEN TOOLS TO FIGURE OUT WHAT 1284 00:45:41,498 --> 00:45:45,969 PREEXISTING FACTORS PUT YOU AT 1285 00:45:45,969 --> 00:45:47,404 HIGHEST RISK, WHAT MEDICATIONS 1286 00:45:47,404 --> 00:45:49,073 MIGHT BE MOST PROTECTIVE AND 1287 00:45:49,073 --> 00:45:51,075 EFFECTIVE FOR TREATMENT. 1288 00:45:51,075 --> 00:45:53,711 THERE ARE SO MANY OBLIGATIONS 1289 00:45:53,711 --> 00:45:55,112 AS PAYERS, ON CMS, ON 1290 00:45:55,112 --> 00:45:56,513 GOVERNMENT, ON THE PRIVATE 1291 00:45:56,513 --> 00:45:59,483 SECTOR, ON US AS PATIENTS AND 1292 00:45:59,483 --> 00:46:01,352 CLINICIANS TO FIGURE OUT HOW WE 1293 00:46:01,352 --> 00:46:03,454 USE THIS DATA IN A LOT MORE 1294 00:46:03,454 --> 00:46:05,289 EFFICIENT WAY AND MAKE IT 1295 00:46:05,289 --> 00:46:07,191 AVAILABLE SO WE CAN ANALYZE IT 1296 00:46:07,191 --> 00:46:08,158 DURING TIMES OF ESPECIALLY DEM 1297 00:46:08,158 --> 00:46:10,160 EC AND CRISIS. 1298 00:46:10,160 --> 00:46:11,562 EITHER DEATH REPORTS NEED TO BE 1299 00:46:11,562 --> 00:46:12,529 STANDARDIZE. 1300 00:46:12,529 --> 00:46:14,631 IF YOU DIE FROM SECONDARY 1301 00:46:14,631 --> 00:46:16,266 EFFECTS OF A HURRICANE, THAT'S 1302 00:46:16,266 --> 00:46:18,102 NOT COUNTED AS A HURRICANE 1303 00:46:18,102 --> 00:46:20,437 DEATH AND IN FLORIDA IT IS. 1304 00:46:20,437 --> 00:46:22,573 WE DON'T EVEN AGREE ON WHAT 1305 00:46:22,573 --> 00:46:23,407 DISASTER DEATHS MEAN ACROSS THE 1306 00:46:23,407 --> 00:46:24,208 UNITED STATES. 1307 00:46:24,208 --> 00:46:27,311 WE NEED TO DO A LOT MORE WORK 1308 00:46:27,311 --> 00:46:28,645 ON SURVIVABILITY MODELS. 1309 00:46:28,645 --> 00:46:30,280 THERE'S NO REASON WITH TOOLS 1310 00:46:30,280 --> 00:46:33,784 AVAILABLE AND THE DATA 1311 00:46:33,784 --> 00:46:34,952 AVAILABLE WE CAN'T 1312 00:46:34,952 --> 00:46:36,420 SIGNIFICANTLY IMPROVE OUR 1313 00:46:36,420 --> 00:46:37,755 PROGNOSTICATION, I CAN'T STAND 1314 00:46:37,755 --> 00:46:40,524 THE FACT WHEN I WATCH PLAYOFF 1315 00:46:40,524 --> 00:46:44,595 FOOTBALL I CAN BE TOLD EXACTLY 1316 00:46:44,595 --> 00:46:45,796 SUCCESSFUL CONVERSION OF A 1317 00:46:45,796 --> 00:46:48,565 FOURTH DOWN IS, BUT WHEN 1318 00:46:48,565 --> 00:46:51,101 SOMEONE AT THE BEDSIDE ASKS ME 1319 00:46:51,101 --> 00:46:54,405 WHAT THE PROBABILITY OF THEIR 1320 00:46:54,405 --> 00:46:56,273 LOVED ONES DYING, I CAN'T GIVE 1321 00:46:56,273 --> 00:46:58,308 MORE THAN A BALLPARK. 1322 00:46:58,308 --> 00:47:00,210 WE NEED TO MANAGE END OF LIFE 1323 00:47:00,210 --> 00:47:02,212 DECISIONS IN THE U.S. 1324 00:47:02,212 --> 00:47:03,714 I WON'T DWELL ON THAT HERE. 1325 00:47:03,714 --> 00:47:04,882 BUT WE HAVE SO MANY 1326 00:47:04,882 --> 00:47:06,550 OPPORTUNITIES TO FIGURE OUT HOW 1327 00:47:06,550 --> 00:47:10,754 TO BETTER SERVE OUR AT-RISK 1328 00:47:10,754 --> 00:47:12,156 COMMUNITIES, TREATMENT, 1329 00:47:12,156 --> 00:47:12,689 ASSESSMENTS, INTEGRATING 1330 00:47:12,689 --> 00:47:14,858 DEVICES AS WE MOVE FORWARD. 1331 00:47:14,858 --> 00:47:16,326 BOTH PERSONAL DEVICES WHETHER 1332 00:47:16,326 --> 00:47:19,363 YOUR SMART WATCH OR ACTUAL 1333 00:47:19,363 --> 00:47:21,698 BIOMEDICAL DEVICES TO LET THEM 1334 00:47:21,698 --> 00:47:24,201 DO THINGS INDEPENDENT WITHIN 1335 00:47:24,201 --> 00:47:28,672 PARAMETERS SET BY THE 1336 00:47:28,672 --> 00:47:31,708 CLINICIANS TO REDUCE WORK 1337 00:47:31,708 --> 00:47:33,277 FATIGUE, AMONG OTHER THINGS. 1338 00:47:33,277 --> 00:47:35,012 ON THE STAFF SIDE, WE NEED TO 1339 00:47:35,012 --> 00:47:36,647 FIGURE OUT WHERE THE STAFF 1340 00:47:36,647 --> 00:47:38,715 COULD BE BEST USE, THEIR 1341 00:47:38,715 --> 00:47:40,317 EXPERTISE COULD BE BEST USED 1342 00:47:40,317 --> 00:47:43,854 AND IF THAT LACK OF EXPERTISE 1343 00:47:43,854 --> 00:47:45,355 IS CONTRIBUTING SUBSTANTIALLY 1344 00:47:45,355 --> 00:47:45,622 TO DEATH. 1345 00:47:45,622 --> 00:47:47,424 IT PROBABLY IS. 1346 00:47:47,424 --> 00:47:49,960 BUT WE NEED TO DEFINE THAT. 1347 00:47:49,960 --> 00:47:52,563 IS IT IN THE I.C.U. OR THE 1348 00:47:52,563 --> 00:47:54,865 FLOOR, PEOPLE ARE BEING PUSHED 1349 00:47:54,865 --> 00:47:57,000 OUT OF I.C.U. TO FLOOR CARE. 1350 00:47:57,000 --> 00:47:58,402 FIGURING OUT ERRORS THAT LEAD 1351 00:47:58,402 --> 00:48:00,571 TO POOR OUTCOMES IS PARAMOUNT 1352 00:48:00,571 --> 00:48:02,406 TO FIXING THOSE ERRORS AND WE 1353 00:48:02,406 --> 00:48:03,807 NEED TO EXPERIENCE WITH 1354 00:48:03,807 --> 00:48:05,209 DIFFERENT STAFFING MODELS TO 1355 00:48:05,209 --> 00:48:06,410 FIGURE OUT WHICH POSE THE 1356 00:48:06,410 --> 00:48:09,179 LOWEST RISK. 1357 00:48:09,179 --> 00:48:10,581 THE LOAD BALANCING STRATEGIES 1358 00:48:10,581 --> 00:48:11,748 WE ARE DISCUSSING THERE'S STILL 1359 00:48:11,748 --> 00:48:15,519 WORK TO BE DONE THERE. 1360 00:48:15,519 --> 00:48:16,954 PROOF OF CONCEPT, WE NEED TO 1361 00:48:16,954 --> 00:48:19,056 PROVE THIS COULD BE DONE AND WE 1362 00:48:19,056 --> 00:48:20,958 NEED TO DEMONSTRATE IT'S 1363 00:48:20,958 --> 00:48:21,925 ESSENTIALLY AN OBLIGATION WHEN 1364 00:48:21,925 --> 00:48:23,093 WE ARE FACED WITH HOSPITALS 1365 00:48:23,093 --> 00:48:24,761 THAT ARE OVER LOADED AND OTHER 1366 00:48:24,761 --> 00:48:25,529 HOSPITALS IN THE AREA THAT ARE 1367 00:48:25,529 --> 00:48:27,064 NOT. 1368 00:48:27,064 --> 00:48:32,669 DEFINING THAT EXCESS MORTALITY 1369 00:48:32,669 --> 00:48:36,673 BETTER AND STATES USING THESE 1370 00:48:36,673 --> 00:48:37,207 LOAD BALANCING PROCEDURES 1371 00:48:37,207 --> 00:48:39,243 EFFECTIVELY. 1372 00:48:39,243 --> 00:48:40,377 HAVING TRIGGERS WHEN WE GET TO 1373 00:48:40,377 --> 00:48:42,379 THRESHOLDS. 1374 00:48:42,379 --> 00:48:44,915 IT'S NON LINEAR AS HOSPITALS 1375 00:48:44,915 --> 00:48:45,949 INCREASE DEMAND AND INCREASE 1376 00:48:45,949 --> 00:48:46,817 CASELOADS. 1377 00:48:46,817 --> 00:48:48,919 WHICH IS THE POINT WE WILL 1378 00:48:48,919 --> 00:48:50,320 TRIGGER LOAD BALANCING AND HOW 1379 00:48:50,320 --> 00:48:53,824 DO WE MAKE SURE THE HOSPITALS 1380 00:48:53,824 --> 00:48:57,060 ARE OBLIGATED TO COOPERATE EVEN 1381 00:48:57,060 --> 00:48:58,695 BETWEEN HEALTHCARE SYSTEMS AND 1382 00:48:58,695 --> 00:48:59,296 FIGURING OUT PLATFORMS TO DO 1383 00:48:59,296 --> 00:49:00,797 THIS. 1384 00:49:00,797 --> 00:49:02,666 I DON'T FORESEE A GOVERNMENT 1385 00:49:02,666 --> 00:49:03,600 PLATFORM BEING ESTABLISHED ANY 1386 00:49:03,600 --> 00:49:04,968 TIME SOON. 1387 00:49:04,968 --> 00:49:06,637 DATA IS ONE THING, ANALYTICS 1388 00:49:06,637 --> 00:49:08,772 AND USE OF THE DATA ARE OTHER 1389 00:49:08,772 --> 00:49:09,740 THINGS WE NEED TO CONTINUE TO 1390 00:49:09,740 --> 00:49:10,741 WORK ON. 1391 00:49:10,741 --> 00:49:11,675 THERE'S A LOT OF SOLUTIONS 1392 00:49:11,675 --> 00:49:13,010 AHEAD. 1393 00:49:13,010 --> 00:49:15,078 TECHNOLOGY OFFERS A LOT OF 1394 00:49:15,078 --> 00:49:16,513 SOLUTIONS TO IMPROVE OUR 1395 00:49:16,513 --> 00:49:17,481 CLINICAL WORKFLOW AT THE 1396 00:49:17,481 --> 00:49:20,217 BEDSIDE. 1397 00:49:20,217 --> 00:49:22,152 INFORMATICS OFFERS US BOTH DATA 1398 00:49:22,152 --> 00:49:23,520 TO BOTH FORWARD AND FOSTER 1399 00:49:23,520 --> 00:49:25,055 THOSE SOLUTIONS BUT ALSO GIVES 1400 00:49:25,055 --> 00:49:28,959 US DATA TO WORK WITH ON PATIENT 1401 00:49:28,959 --> 00:49:30,594 PLACEMENT, SO OUR COORDINATION 1402 00:49:30,594 --> 00:49:31,995 CENTERS CAN GET PEOPLE TO THE 1403 00:49:31,995 --> 00:49:35,432 RIGHT PLACE AT THE RIGHT TIME 1404 00:49:35,432 --> 00:49:35,766 FOR TREATMENT. 1405 00:49:35,766 --> 00:49:38,235 AGAIN, BRINGING UP THE FACT 1406 00:49:38,235 --> 00:49:40,771 THESE SCARCITY DRIVEN ISSUE 1407 00:49:40,771 --> 00:49:41,939 THEZ REFLECT PATIENT SAFETY 1408 00:49:41,939 --> 00:49:43,540 ISSUES ON A DAILY BASIS. 1409 00:49:43,540 --> 00:49:45,809 THIS ISN'T JUST ABOUT DISASTERS. 1410 00:49:45,809 --> 00:49:47,511 WHAT WE LEARN FROM THESE 1411 00:49:47,511 --> 00:49:48,912 SITUATIONS CAN HELP INFORM 1412 00:49:48,912 --> 00:49:51,715 BETTER PATIENT CARE ON A DAILY 1413 00:49:51,715 --> 00:49:53,850 BASIS AND DRIVE RESEARCH THAT 1414 00:49:53,850 --> 00:49:55,218 CAN FURTHER PATIENT SAFETY, 1415 00:49:55,218 --> 00:49:57,554 HOPEFULLY THAT WILL DRIVE 1416 00:49:57,554 --> 00:50:00,591 REGULATORY CHANGE, THAT WILL 1417 00:50:00,591 --> 00:50:02,492 DRIVE REIMBURSEMENT CHANGES FOR 1418 00:50:02,492 --> 00:50:04,795 PREPAREDNESS FOR SURGE EVENTS 1419 00:50:04,795 --> 00:50:06,463 WHICH WE DON'T CURRENTLY HAVE. 1420 00:50:06,463 --> 00:50:10,500 A COUPLE RESOURCE ARTICLES. 1421 00:50:10,500 --> 00:50:12,069 PERSPECTIVES PIECE NATIONAL 1422 00:50:12,069 --> 00:50:13,270 ACADEMIES OF MEDICINE. 1423 00:50:13,270 --> 00:50:15,405 WHAT DID WE LEARN ABOUT CRISIS 1424 00:50:15,405 --> 00:50:17,040 CENTERS OF CARE DURING COVID 1425 00:50:17,040 --> 00:50:18,308 AND HOW DOES THAT NEED TO 1426 00:50:18,308 --> 00:50:19,810 CHANGE GOING FORWARD. 1427 00:50:19,810 --> 00:50:22,813 THE JOINT COMMISSION I 1428 00:50:22,813 --> 00:50:23,780 MENTIONED FOCUSED ON CLINICIANS 1429 00:50:23,780 --> 00:50:29,920 AT A HOSPITAL WHEN FACED WITH 1430 00:50:29,920 --> 00:50:31,588 EXCESS DEMANDS. 1431 00:50:31,588 --> 00:50:32,289 SO ALLOCATIONS ARE JUST AND 1432 00:50:32,289 --> 00:50:34,625 FAIR. 1433 00:50:34,625 --> 00:50:36,493 BOTH ARE OPEN ACCESS AND 1434 00:50:36,493 --> 00:50:37,894 HOPEFULLY WILL BE HELPFUL IF 1435 00:50:37,894 --> 00:50:39,596 YOU ARE INTERESTED A LITTLE 1436 00:50:39,596 --> 00:50:42,432 MORE ON THE POLICY SIDES AND 1437 00:50:42,432 --> 00:50:43,333 FUTURE LOOKING SIDES OF THIS 1438 00:50:43,333 --> 00:50:44,267 CONVERSATION. 1439 00:50:44,267 --> 00:50:45,602 AGAIN, THAT'S A LOT IN A LITTLE 1440 00:50:45,602 --> 00:50:47,437 BIT OF TIME. 1441 00:50:47,437 --> 00:50:48,271 I GENUINELY APPRECIATE YOUR 1442 00:50:48,271 --> 00:50:49,673 INTEREST IN THE TOPIC AND YOUR 1443 00:50:49,673 --> 00:50:52,776 TIME TODAY AND THE INVITATION 1444 00:50:52,776 --> 00:50:53,443 TO COME SPEAK. 1445 00:50:53,443 --> 00:50:56,213 I WILL TURN IT BACK TO HENRY 1446 00:50:56,213 --> 00:50:57,214 FOR QUESTIONS. 1447 00:50:57,214 --> 00:50:59,583 >> THANK YOU, JOHN. 1448 00:50:59,583 --> 00:51:00,651 TWO PERSPECTIVES, WE USUALLY 1449 00:51:00,651 --> 00:51:01,885 DON'T GET INTO. 1450 00:51:01,885 --> 00:51:04,488 ONE IS FROM A POPULATION 1451 00:51:04,488 --> 00:51:06,523 MEDICINE POINT OF VIEW THAT 1452 00:51:06,523 --> 00:51:07,290 SAMEER PRESENTED. 1453 00:51:07,290 --> 00:51:10,127 AND THE OTHER IS FROM A 1454 00:51:10,127 --> 00:51:11,528 DISASTER MANAGEMENT PERSPECTIVE. 1455 00:51:11,528 --> 00:51:13,664 BUT BEFORE WE TAKE A FEW 1456 00:51:13,664 --> 00:51:15,365 QUESTIONS, LET ME ASK SAMEER 1457 00:51:15,365 --> 00:51:18,368 AND JOHN, IF YOU ARE A 1458 00:51:18,368 --> 00:51:19,736 CLINICIAN IN MARYLAND, MARYLAND 1459 00:51:19,736 --> 00:51:21,038 HAD A UNIQUE SYSTEM FOR DEALING 1460 00:51:21,038 --> 00:51:22,406 WITH THIS. 1461 00:51:22,406 --> 00:51:23,740 CAN YOU DESCRIBE VERY BRIEFLY. 1462 00:51:23,740 --> 00:51:25,809 IF YOU WERE A CLINICIAN AT ONE 1463 00:51:25,809 --> 00:51:29,112 OF THE HOSPITALS, HOW DID YOU 1464 00:51:29,112 --> 00:51:30,781 TRIAGE PATIENTS IN MARYLAND AND 1465 00:51:30,781 --> 00:51:33,383 HOW THAT WORKED, IF YOU COULD 1466 00:51:33,383 --> 00:51:35,485 SAY IN 90 SECONDS OR LESS, AND 1467 00:51:35,485 --> 00:51:36,253 JOHN CAN MAYBE TALK ABOUT 1468 00:51:36,253 --> 00:51:38,355 MINNESOTA. 1469 00:51:38,355 --> 00:51:39,156 >> THANK YOU, HENRY, FOR THE 1470 00:51:39,156 --> 00:51:40,223 QUESTION. 1471 00:51:40,223 --> 00:51:40,891 IT'S A DIFFICULT QUESTION TO 1472 00:51:40,891 --> 00:51:41,858 ANSWER. 1473 00:51:41,858 --> 00:51:43,160 BECAUSE WE ARE NOT TALKING 1474 00:51:43,160 --> 00:51:44,661 ABOUT ONE POINT IN TIME. 1475 00:51:44,661 --> 00:51:45,996 AND NOT TALKING ABOUT ONE TYPE 1476 00:51:45,996 --> 00:51:47,731 OF HOSPITAL. 1477 00:51:47,731 --> 00:51:49,332 MARYLAND, AS YOU KNOW, IS A 1478 00:51:49,332 --> 00:51:51,001 DIVERSE SET OF HOSPITALS IN 1479 00:51:51,001 --> 00:51:52,169 TERMS OF THEIR CAPABILITIES. 1480 00:51:52,169 --> 00:51:54,271 AND IN TERMS OF THE SERVICE 1481 00:51:54,271 --> 00:51:55,172 THAT'S WERE PROVIDED DURING THE 1482 00:51:55,172 --> 00:51:57,074 PANDEMIC. 1483 00:51:57,074 --> 00:51:59,409 AND YOU KNOW, DURING THE COURSE 1484 00:51:59,409 --> 00:52:01,712 OF THE PANDEMIC, MARYLAND 1485 00:52:01,712 --> 00:52:04,314 DEVELOPED A TRANSFER 1486 00:52:04,314 --> 00:52:05,482 COORDINATION CENTER, THAT 1487 00:52:05,482 --> 00:52:09,052 REALLY DID A GOOD JOB BASED ON 1488 00:52:09,052 --> 00:52:10,854 MY CONVERSATIONS WITH PEOPLE IN 1489 00:52:10,854 --> 00:52:12,723 THE LEADERSHIP AT THIS CENTER, 1490 00:52:12,723 --> 00:52:17,394 THEY WERE ABLE TO ACTUALLY 1491 00:52:17,394 --> 00:52:19,096 PLACE ABOUT 70-75% OF THE CALLS 1492 00:52:19,096 --> 00:52:21,364 THAT THEY GOT. 1493 00:52:21,364 --> 00:52:23,433 THEY WERE ABLE TO PROVIDE 1494 00:52:23,433 --> 00:52:24,835 ADVICE FOR CARE IN PLACE FOR 1495 00:52:24,835 --> 00:52:27,104 THE REST OF THEM. 1496 00:52:27,104 --> 00:52:28,839 I THINK IF YOU LOOK AT IT, I 1497 00:52:28,839 --> 00:52:30,707 THINK YOU WANT TO LOOK AT IT 1498 00:52:30,707 --> 00:52:32,843 NOT ONLY FROM ONE STATE'S 1499 00:52:32,843 --> 00:52:33,977 PERSPECTIVE BUT IN COMPARISON 1500 00:52:33,977 --> 00:52:36,113 TO REST OF THE COUNTRY. 1501 00:52:36,113 --> 00:52:38,882 DIFFERENT STATES DID ZHIFRNGS. 1502 00:52:38,882 --> 00:52:40,083 DIFFERENT THINGS. 1503 00:52:40,083 --> 00:52:42,219 THERE WERE SOME STATES NOT ABLE 1504 00:52:42,219 --> 00:52:44,121 TO GET THAT LEVEL OF SUCCESS. 1505 00:52:44,121 --> 00:52:46,289 I THINK MARYLAND HAS A LOT TO 1506 00:52:46,289 --> 00:52:47,424 OFFER LESSONS FOR OTHER STATES 1507 00:52:47,424 --> 00:52:48,925 IN THE FUTURE WE COULD LEARN 1508 00:52:48,925 --> 00:52:49,860 FROM. 1509 00:52:49,860 --> 00:52:50,761 TO SPECIFICALLY ANSWER YOUR 1510 00:52:50,761 --> 00:52:54,064 QUESTION, IF I WAS A PHYSICIAN, 1511 00:52:54,064 --> 00:52:55,432 I ENCOUNTERED SITUATIONS WHERE 1512 00:52:55,432 --> 00:53:01,004 I COULD NOT ACCEPT A PATIENT 1513 00:53:01,004 --> 00:53:02,639 WHO NEEDED CONTINUOUS RENAL 1514 00:53:02,639 --> 00:53:03,573 REPLACEMENT THERAPY BECAUSE 1515 00:53:03,573 --> 00:53:05,642 ONLY I COULD PROVIDE IT AT MY 1516 00:53:05,642 --> 00:53:06,843 I.C.U. 1517 00:53:06,843 --> 00:53:08,945 IT WAS DISTRESSING. 1518 00:53:08,945 --> 00:53:12,015 THIS IS ONE ANECDOTE, BUT JUST 1519 00:53:12,015 --> 00:53:13,517 IMAGINE, ONE PHYSICIAN IN THE 1520 00:53:13,517 --> 00:53:15,152 I.C.U. AND THERE ARE SO MANY. 1521 00:53:15,152 --> 00:53:18,355 AND THERE WERE SO MANY SUCH 1522 00:53:18,355 --> 00:53:19,089 SCENARIOS, COLLECTIVELY 1523 00:53:19,089 --> 00:53:20,724 POPULATION SCIENCE REALLY HELPS 1524 00:53:20,724 --> 00:53:22,626 TO CAPTURE THE BREADTH OF THIS 1525 00:53:22,626 --> 00:53:24,961 DISTRESS. 1526 00:53:24,961 --> 00:53:28,231 >> SAMEER, AT LEAST IN MARYLAND 1527 00:53:28,231 --> 00:53:30,801 YOU HAD A PHONE NUMBER YOU 1528 00:53:30,801 --> 00:53:31,701 COULD CALL, EMERGENCY 1529 00:53:31,701 --> 00:53:33,170 MANAGEMENT SERVICE THAT'S WOULD 1530 00:53:33,170 --> 00:53:34,104 HAVE COORDINATED THAT FOR YOU. 1531 00:53:34,104 --> 00:53:35,605 I GUESS THAT'S PART OF WHAT YOU 1532 00:53:35,605 --> 00:53:36,706 WORKED AT ALSO. 1533 00:53:36,706 --> 00:53:38,341 HOW DID THAT WORK IN MINNESOTA, 1534 00:53:38,341 --> 00:53:40,177 JOHN, IF YOU WERE A CLINICIAN 1535 00:53:40,177 --> 00:53:41,211 IN A COMMUNITY HOSPITAL? 1536 00:53:41,211 --> 00:53:42,946 >> GREAT QUESTION, FIRST 1537 00:53:42,946 --> 00:53:44,681 REFLECTING ON MARYLAND, THEY 1538 00:53:44,681 --> 00:53:47,284 HAVE A LONG HISTORY OF 1539 00:53:47,284 --> 00:53:48,652 CENTRALIZED E.M.S. AND WAS ABLE 1540 00:53:48,652 --> 00:53:50,420 TO BUILD OFF THAT IN A VERY 1541 00:53:50,420 --> 00:53:54,825 SUCCESSFUL WAY. 1542 00:53:54,825 --> 00:53:57,160 DAVE MARCOSY AND KALYN HAD 1543 00:53:57,160 --> 00:53:59,996 TRIGGERS WHEN WE ENTER CRISIS 1544 00:53:59,996 --> 00:54:02,566 OF CARE, NEW ENGLAND JOURNAL OF 1545 00:54:02,566 --> 00:54:05,135 MEDICINE A LITTLE WHILE AGO. 1546 00:54:05,135 --> 00:54:06,937 FRAMEWORK THAT COULD PROBABLY 1547 00:54:06,937 --> 00:54:08,171 BE APPLIED NATIONALLY, HOW DO 1548 00:54:08,171 --> 00:54:09,706 WE ALL AGREE WHEN WE HIT THAT 1549 00:54:09,706 --> 00:54:11,942 TIPPING POINT. 1550 00:54:11,942 --> 00:54:13,610 I THINK WHAT CLINICIANS ASKED 1551 00:54:13,610 --> 00:54:16,613 FOR IS MORE ABILITY TO COMPEL 1552 00:54:16,613 --> 00:54:18,982 TRANSFERS WHEN A PATIENT WAS 1553 00:54:18,982 --> 00:54:20,150 CLEARLY NOT RECEIVING EMERGENCY 1554 00:54:20,150 --> 00:54:21,318 CARE THEY NEEDED BECAUSE THE 1555 00:54:21,318 --> 00:54:23,420 HOSPITAL THEY WERE IN COULDN'T 1556 00:54:23,420 --> 00:54:26,022 PROVIDE IT, WHETHER TRAUMA 1557 00:54:26,022 --> 00:54:27,657 CARE, DIALYSIS, WHATEVER, TO 1558 00:54:27,657 --> 00:54:29,626 HAVE A STANDARDIZED PROCESS FOR 1559 00:54:29,626 --> 00:54:31,361 MANAGING. 1560 00:54:31,361 --> 00:54:32,996 WHETHER ALTERNATING BETWEEN 1561 00:54:32,996 --> 00:54:34,664 TERTIARY CENTERS OR SOME OTHER 1562 00:54:34,664 --> 00:54:36,499 WAY TO MANAGE THAT PATIENT WHO 1563 00:54:36,499 --> 00:54:38,768 IS VERY, VERY HIGH PRIORITY. 1564 00:54:38,768 --> 00:54:39,903 AND JUST A RECOGNITION WE ARE 1565 00:54:39,903 --> 00:54:41,972 ALL IN THIS TOGETHER. 1566 00:54:41,972 --> 00:54:44,541 YOU ARE MAKING TOUGH CHOICES. 1567 00:54:44,541 --> 00:54:51,514 WE WILL MAINTAIN THAT AND 1568 00:54:51,514 --> 00:54:53,583 CONTINUE FOR CONSISTENCY. 1569 00:54:53,583 --> 00:54:55,685 PATIENTS WERE BEING PUT AT RISK 1570 00:54:55,685 --> 00:54:56,686 AND DYING. 1571 00:54:56,686 --> 00:54:59,756 WE DIDN'T SEE A REFLECTION OF 1572 00:54:59,756 --> 00:55:00,924 THAT OUTWARD, PARTIALLY THEY 1573 00:55:00,924 --> 00:55:01,992 DIDN'T WANT TO ADMIT THINGS 1574 00:55:01,992 --> 00:55:03,593 WERE THAT BAD. 1575 00:55:03,593 --> 00:55:05,362 SAME PROCESS, THE TOLL FREE 1576 00:55:05,362 --> 00:55:07,964 NUMBER YOU CALLED, EARLY ON IN 1577 00:55:07,964 --> 00:55:09,833 THE PANDEMIC IT WORKED REALLY 1578 00:55:09,833 --> 00:55:12,168 WELL, WE PLACED 100% OF 1579 00:55:12,168 --> 00:55:13,803 PATIENTS AFTER THE EMERGENCY 1580 00:55:13,803 --> 00:55:15,171 DECLARATION WENT AWAY AND THERE 1581 00:55:15,171 --> 00:55:17,274 WAS NO WAY TO COMPEL 1582 00:55:17,274 --> 00:55:18,875 PARTICIPATION IN THAT, OUR 1583 00:55:18,875 --> 00:55:23,079 ABILITY TO PLACE THOSE TRANSFER 1584 00:55:23,079 --> 00:55:24,714 PATIENTS FELL OFF PRECIPITOUSLY. 1585 00:55:24,714 --> 00:55:26,249 MUCH TO CORRECT GOING FORWARD 1586 00:55:26,249 --> 00:55:28,551 POLICY-WISE. 1587 00:55:28,551 --> 00:55:38,929 >> ANY OTHER QUESTIONS HERE? 1588 00:55:38,929 --> 00:55:40,096 TOM BERKLOW HAS QUESTIONS. 1589 00:55:40,096 --> 00:55:45,435 >> A COMMENT FIRST. 1590 00:55:45,435 --> 00:55:47,103 ACTUALLY, FIELD MARSHAL HELMET 1591 00:55:47,103 --> 00:55:48,939 -- IN THE 1800'S SAID 1592 00:55:48,939 --> 00:55:50,573 SOMETHING TO PARAPHRASE HIM 1593 00:55:50,573 --> 00:55:51,975 THAT NO PLAN SURVIVES FIRST 1594 00:55:51,975 --> 00:55:53,510 CONTACT WITH THE ENEMY. 1595 00:55:53,510 --> 00:55:54,844 I THINK IN EFFECT THAT'S A 1596 00:55:54,844 --> 00:55:57,180 LITTLE BIT OF WHAT WE SAW. 1597 00:55:57,180 --> 00:55:58,148 DISAPPOINTINGLY THE PLANS THAT 1598 00:55:58,148 --> 00:56:00,250 WE HAD IN PLACE HOW WE ARE 1599 00:56:00,250 --> 00:56:03,320 GOING TO ADDRESS SOME SORT OF 1600 00:56:03,320 --> 00:56:05,755 DISASTER OF THIS GLOBAL NATURE 1601 00:56:05,755 --> 00:56:07,223 REALLY PROVED INADEQUATE. 1602 00:56:07,223 --> 00:56:09,125 I GUESS FOR ME, BECAUSE I'M NOT 1603 00:56:09,125 --> 00:56:10,794 INVOLVED IN THIS SPACE, YOU 1604 00:56:10,794 --> 00:56:11,828 KNOW, THERE WERE LESSONS 1605 00:56:11,828 --> 00:56:13,129 LEARNED. 1606 00:56:13,129 --> 00:56:14,998 AND I APPRECIATE YOUR BOTH 1607 00:56:14,998 --> 00:56:16,132 EXCELLENT PRESENTATIONS AND 1608 00:56:16,132 --> 00:56:18,435 PUTTING A SPOTLIGHT ON YOUR 1609 00:56:18,435 --> 00:56:21,471 WORK AND THE HEROIC EFFORTS YOU 1610 00:56:21,471 --> 00:56:23,139 PUT INTO TRYING TO ADDRESS THIS. 1611 00:56:23,139 --> 00:56:25,809 WE HAVE A VERY DECENTRALIZED 1612 00:56:25,809 --> 00:56:26,409 HEALTHCARE SYSTEM IN OUR 1613 00:56:26,409 --> 00:56:28,278 COUNTRY. 1614 00:56:28,278 --> 00:56:30,547 THAT ALLOWS FLEXIBILITY, BUT 1615 00:56:30,547 --> 00:56:33,249 ALSO, I THINK IT KEPT US 1616 00:56:33,249 --> 00:56:33,783 FROMING HAVE MORE UNIFIED 1617 00:56:33,783 --> 00:56:34,884 RESPONSES. 1618 00:56:34,884 --> 00:56:37,454 AS WE GO FORWARD, I DO WORRY 1619 00:56:37,454 --> 00:56:39,322 THAT WE ARE LOSING SIGHT OF 1620 00:56:39,322 --> 00:56:41,925 SOME OF THE LESSONS LEARNED. 1621 00:56:41,925 --> 00:56:43,793 FROM Y'ALL'S PERSPECTIVE, WHAT 1622 00:56:43,793 --> 00:56:45,895 ARE THE FORMS, IT SEEMS THIS 1623 00:56:45,895 --> 00:56:47,831 HAS TO BE ADDRESSED AT THE 1624 00:56:47,831 --> 00:56:50,100 STATE HEALTH LEVELS. 1625 00:56:50,100 --> 00:56:54,971 ARE THERE FORUMS OR GATHERINGS 1626 00:56:54,971 --> 00:56:57,507 THEY ARE SHARING TO GET BACK TO 1627 00:56:57,507 --> 00:56:58,908 THEIR STATE LEGISLATURES? 1628 00:56:58,908 --> 00:57:01,511 >> WE SHOULD TAKE THAT AND 1629 00:57:01,511 --> 00:57:04,080 ORGANIZE ONE OF THEM. 1630 00:57:04,080 --> 00:57:05,882 >> A COUPLE THINGS. 1631 00:57:05,882 --> 00:57:07,884 ONE IS WE ARE TRYING TO 1632 00:57:07,884 --> 00:57:10,086 PRESERVE THESE LESSONS LEARN 1633 00:57:10,086 --> 00:57:11,821 AND AUGMENT IMPLEMENTATION. 1634 00:57:11,821 --> 00:57:13,289 ONE WAY IS WE HAVE A VIRTUAL 1635 00:57:13,289 --> 00:57:17,594 CONFERENCE. 1636 00:57:17,594 --> 00:57:18,862 ASPR TRACY, GATEWAY FOR 1637 00:57:18,862 --> 00:57:20,497 EMERGENCY PREPAREDNESS. 1638 00:57:20,497 --> 00:57:23,033 WE ARE HOSTING A TWO DAY 1639 00:57:23,033 --> 00:57:24,701 MEDICAL CONFERENCE FOR MEDICAL 1640 00:57:24,701 --> 00:57:26,836 DIRECTORS COMING UP IN FEBRUARY. 1641 00:57:26,836 --> 00:57:29,439 SO THOSE INDIVIDUALS WHO ARE 1642 00:57:29,439 --> 00:57:30,607 DIRECTORS OF THEIR E.M.S. 1643 00:57:30,607 --> 00:57:32,242 SERVICES OR THE STATE LEVEL CAN 1644 00:57:32,242 --> 00:57:33,410 COME TOGETHER AND TRY TO 1645 00:57:33,410 --> 00:57:35,045 CONTINUE TO WORK TOGETHER TO 1646 00:57:35,045 --> 00:57:35,745 PROBLEM SOLVE AND MOVE THIS 1647 00:57:35,745 --> 00:57:36,679 FORWARD. 1648 00:57:36,679 --> 00:57:39,015 I WILL SAY SOME OF THE 1649 00:57:39,015 --> 00:57:40,650 SOLUTIONS LIKE THE MOCKS 1650 00:57:40,650 --> 00:57:44,154 FEATURE VERY HEAVILY IN THE 1651 00:57:44,154 --> 00:57:44,854 UPCOMING FIVE-YEAR HEALTHCARE 1652 00:57:44,854 --> 00:57:46,923 CAPABILITIES FOR THE NATION, 1653 00:57:46,923 --> 00:57:49,192 THAT ASPR WILL BE PUTTING OUT 1654 00:57:49,192 --> 00:57:51,327 HERE IN THE NEXT FEW MONTHS. 1655 00:57:51,327 --> 00:57:54,798 THOSE WILL BE INTEGRATED IN THE 1656 00:57:54,798 --> 00:57:55,265 HOSPITAL PREPAREDNESS 1657 00:57:55,265 --> 00:57:55,999 REQUIREMENTS GOING FORWARD. 1658 00:57:55,999 --> 00:57:58,535 I THINK YOU ARE LIKELY TO SEE 1659 00:57:58,535 --> 00:57:59,936 MORE TRACTION ON MOX. 1660 00:57:59,936 --> 00:58:01,838 I'M HOPEFUL AS WE ARE PREPARED 1661 00:58:01,838 --> 00:58:04,674 TO RAISE THESE PATIENT SAFETY 1662 00:58:04,674 --> 00:58:05,942 ISSUES, CMS AND REGULATORS WILL 1663 00:58:05,942 --> 00:58:07,510 LOOK MORE CLOSELY AND WILL BE 1664 00:58:07,510 --> 00:58:09,312 MUCH MORE INTERESTED IN HELPING 1665 00:58:09,312 --> 00:58:11,414 US COLLECT THE OPERATIONAL DATA 1666 00:58:11,414 --> 00:58:12,782 THAT INDICATES WHEN HOSPITALS 1667 00:58:12,782 --> 00:58:15,118 ARE OVER THEIR USUAL CAPACITY 1668 00:58:15,118 --> 00:58:16,853 AND CONTRIBUTE TO LOAD 1669 00:58:16,853 --> 00:58:17,921 BALANCING SOLUTIONS. 1670 00:58:17,921 --> 00:58:19,956 I HOPE THERE'S A MULTI-PRONGED 1671 00:58:19,956 --> 00:58:22,092 FOCUS TO TRY TO TAKE THOSE 1672 00:58:22,092 --> 00:58:24,427 LESSONS AND TRY TO BOTH WITHIN 1673 00:58:24,427 --> 00:58:26,329 POLICY AND PROGRAM MAKE SURE WE 1674 00:58:26,329 --> 00:58:27,497 ARE CAPTURING SOME OF THOSE 1675 00:58:27,497 --> 00:58:28,665 ISSUES. 1676 00:58:28,665 --> 00:58:30,066 >> JOHN, NOW THAT YOU ARE 1677 00:58:30,066 --> 00:58:32,402 WORKING IN HEALTH AND HUMAN 1678 00:58:32,402 --> 00:58:34,003 SERVICES, DO YOU THINK THEN 1679 00:58:34,003 --> 00:58:36,339 THERE WOULD BE MORE FINANCING 1680 00:58:36,339 --> 00:58:37,974 FOR DISASTER PREPAREDNESS AND 1681 00:58:37,974 --> 00:58:39,142 PUTTING SYSTEMS IN PLACE THAT 1682 00:58:39,142 --> 00:58:42,912 ARE ACTUALLY READY TO GO WHEN 1683 00:58:42,912 --> 00:58:43,446 THE DISASTER UNEXPECTEDLY 1684 00:58:43,446 --> 00:58:44,314 OCCURS? 1685 00:58:44,314 --> 00:58:45,949 >> I HOPE SO. 1686 00:58:45,949 --> 00:58:47,584 I THINK A GOOD MODEL IS WITH 1687 00:58:47,584 --> 00:58:48,985 DIALYSIS. 1688 00:58:48,985 --> 00:58:53,089 THERE'S A FEW PENNIES FOR EVERY 1689 00:58:53,089 --> 00:58:53,690 DIALYSIS PATIENTS PERFORMED 1690 00:58:53,690 --> 00:58:55,391 THAT HAVE TO GO TO DIALYSIS 1691 00:58:55,391 --> 00:58:56,993 PREPAREDNESS. 1692 00:58:56,993 --> 00:58:59,496 THAT'S BEEN AN INCREDIBLY 1693 00:58:59,496 --> 00:59:01,631 SUCCESSFUL MODEL, ONE OF THE 1694 00:59:01,631 --> 00:59:03,266 REASONS WE SEE DIALYSIS THE WAY 1695 00:59:03,266 --> 00:59:05,135 IT IS WITHIN THE UNITED STATES, 1696 00:59:05,135 --> 00:59:07,003 I THINK THERE'S PRECEDENT THERE. 1697 00:59:07,003 --> 00:59:09,606 I ALSO THINK THERE'S A DEFINITE 1698 00:59:09,606 --> 00:59:11,741 NEED FOR METRICS FOR 1699 00:59:11,741 --> 00:59:12,909 PREPAREDNESS, WITH HOSPITALS. 1700 00:59:12,909 --> 00:59:15,945 A LOT OF THE REQUIREMENTS JOINT 1701 00:59:15,945 --> 00:59:17,080 COMMISSION AND OTHER REGULATORS 1702 00:59:17,080 --> 00:59:17,714 HAVE AROUND PROCESS. 1703 00:59:17,714 --> 00:59:19,682 DO YOU HAVE A COMMITTEE? 1704 00:59:19,682 --> 00:59:21,451 DO YOU HAVE SOMETHING ELSE. 1705 00:59:21,451 --> 00:59:24,387 I THINK TRYING TO DRILL DOWN TO 1706 00:59:24,387 --> 00:59:25,522 METRICS AND HOLDING HOSPITALS 1707 00:59:25,522 --> 00:59:27,390 ACCOUNTABLE FOR CERTAIN 1708 00:59:27,390 --> 00:59:28,558 CAPACITIES OF EXPANSION BOTH OF 1709 00:59:28,558 --> 00:59:30,560 STAFF AND SPACE WILL BE REALLY 1710 00:59:30,560 --> 00:59:32,862 CRITICAL GOING FORWARD. 1711 00:59:32,862 --> 00:59:35,231 >> THANK YOU, JOHN. 1712 00:59:35,231 --> 00:59:38,034 I WOULD LIKE TO ADD TO WHAT YOU 1713 00:59:38,034 --> 00:59:39,302 ASKED, TOM. 1714 00:59:39,302 --> 00:59:41,604 I THINK PART OF THE PROBLEM, WE 1715 00:59:41,604 --> 00:59:43,339 NEED TO TAKE OWNERSHIP OF WHAT 1716 00:59:43,339 --> 00:59:45,441 WE DID WRONG. 1717 00:59:45,441 --> 00:59:47,110 PART OF THE PROCESS OF GETTING 1718 00:59:47,110 --> 00:59:50,146 MORE PEOPLE TO THE TABLE TO 1719 00:59:50,146 --> 00:59:51,080 MAKE ACTIONABLE DECISIONS 1720 00:59:51,080 --> 00:59:53,483 TOGETHER FOR THE FUTURE AND IN 1721 00:59:53,483 --> 00:59:56,419 REAL-TIME WHEN SOMETHING LIKE 1722 00:59:56,419 --> 00:59:59,455 THIS HAPPENS AGAIN IS PEOPLE 1723 00:59:59,455 --> 01:00:04,093 SHOULD PUBLISH MISHAPPENS. 1724 01:00:04,093 --> 01:00:04,827 MISHAPS AND PUBLISH SYSTEM 1725 01:00:04,827 --> 01:00:06,629 THAT'S DIDN'T WORK. 1726 01:00:06,629 --> 01:00:08,498 THERE'S A PUBLICATION BIAS 1727 01:00:08,498 --> 01:00:09,933 ALSO, OF PROVIDING SUCCESS 1728 01:00:09,933 --> 01:00:11,301 STORIES OF HOW THINGS WORKED 1729 01:00:11,301 --> 01:00:13,636 AND THERE'S NOT THAT MUCH 1730 01:00:13,636 --> 01:00:14,771 MOVEMENT AFTER THAT IN TERMS OF 1731 01:00:14,771 --> 01:00:16,506 ACTION. 1732 01:00:16,506 --> 01:00:17,674 >> YEAH. 1733 01:00:17,674 --> 01:00:20,677 >> I THINK THE FINAL WORD SINCE 1734 01:00:20,677 --> 01:00:24,380 THE HOUR IS UP, IS NIH CAN 1735 01:00:24,380 --> 01:00:25,815 CLEARLY MAKE A CONTRIBUTION IN 1736 01:00:25,815 --> 01:00:27,884 TERMS OF DATA ANALYSIS THAT 1737 01:00:27,884 --> 01:00:28,618 INFORMS POLICY. 1738 01:00:28,618 --> 01:00:29,986 I THINK ONE OF THE POSITIVE 1739 01:00:29,986 --> 01:00:33,923 THINGS THAT CAME OUT OF THIS, 1740 01:00:33,923 --> 01:00:37,227 IS NIH, CDC, FDA, THE ASSISTANT 1741 01:00:37,227 --> 01:00:39,362 SECRETARY FOR PREPAREDNESS ARE 1742 01:00:39,362 --> 01:00:40,830 TALKING MORE AMONGST EACH 1743 01:00:40,830 --> 01:00:41,664 OTHER, TALKING MORE WITH THE 1744 01:00:41,664 --> 01:00:42,565 STATES. 1745 01:00:42,565 --> 01:00:44,234 THE HOPE IS THAT IS NOT GOING 1746 01:00:44,234 --> 01:00:46,603 TO DIE OFF, THAT WILL CONTINUE. 1747 01:00:46,603 --> 01:00:49,639 AGAIN, I THINK THIS WAS A GREAT 1748 01:00:49,639 --> 01:00:51,507 GRAND ROUNDS AND THANK YOU, 1749 01:00:51,507 --> 01:00:57,013 JOHN, FOR COMING FROM MINNESOTA 1750 01:00:57,013 --> 01:00:57,714 AND THANKS, SAMEER. 1751 01:00:57,714 --> 01:00:59,148 THANK YOU. 1752 01:00:59,148 --> 01:01:04,220 [APPLAUSE]