TODAY I THINK WE HAVE A TOPIC
WE ALL ARE INTERESTED IN, IN
TERMS OF SURGE CAPACITY.
DURING COVID, ALL OF US
REALIZED HOSPITALS WERE
INUNDATED WITH PATIENTS.
THEY DIDN'T HAVE ENOUGH PATIENT
BEDS SO THEY USED ALL KIND OF
HEALTHCARE WORKERS TO WORK IN
SITUATIONS THEY WEREN'T
NECESSARILY EXPERIENCED IN.
THE QUESTION IS WHAT DID THAT
DO TO THE QUALITY OF CARE OR
OUTCOMES?
TONIGHT WE ARE FORTUNATE TO
TALK ABOUT "SAVING LIVES WHEN
HOSPITALS ARE SURGING & FUTURE
IMPLICATIONS OF SURGE STRAIN:
LESSONS FROM THE COVID-19
PANDEMIC."
WE HAVE TWO PEOPLE WITH
SLIGHTLY DIFFERENT PERSPECTIVES.
ONE IS SAMEER KADRI, A MEMBER
OF THE CRITICAL MEDICINE
DEPARTMENT IN NIH.
TRAINED IN CRITICAL MEDICINE,
WENT TO HARVARD FOR INFECTIOUS
DISEASE TRAINING.
INTRODUCED TO POPULATION
MEDICINE AND HE CAME BACK HERE
TO START A PROGRAM IN
HEALTHCARE SERVICES RESEARCH.
HE HAS BEEN VERY SUCCESSFUL
WORKING WITH PROFESSIONAL
STUDIES, WORKING WITH THE CDC
AND THE FDA.
HE WILL BE TALKING ABOUT THIS
FROM HIS PERSPECTIVE.
WE ALSO HAVE WITH US, JOHN
HICKS, WHO HAS HAD A VERY
SUCCESSFUL CAREER IN MINNESOTA,
BECOMING A NATIONAL LEADER IN
DISASTER PLANNING AND IN
EMERGENCY PREPAREDNESS.
HE HAS BEEN THE CHIEF OF
EMERGENCY PREPAREDNESS FOR
HAMPTON COUNTY HEALTH AND
HEALTHCARE SERVICES AND BECAUSE
OF HIS EXPERTISE HE IS WORKING
PART-TIME FOR HHS ASSISTANT
SECRETARY FOR PREPAREDNESS SO
HE SPLITS HIS TIME BETWEEN
MINNESOTA AND HERE.
I'M PLEASED TO HAVE THESE TWO
SPEAKERS HERE.
SOSA MERE?
-- SO, SAMEER?
>> Sameer Kadri: THANK YOU VERY
MUCH, DR. MASUR FOR THE KIND
INTRODUCTION AND DR. MERKLO FOR
THE OPPORTUNITY TO PRESENT
RESEARCH ON THE PERILS OF OVER
CROWDING DURING THE PANDEMIC.
OVER THE NEXT 20 MINUTES OR SO,
I WANT TO WALK YOU THROUGH SOME
KEY INSIGHT FROM TEN BIG DATA
INVESTIGATIONS WE CARRIED OUT
DURING THE PANDEMIC.
I HAVE NO FINANCIAL DISCLOSURES.
MANY OF US WANT TO FORGET ABOUT
THE HORRIBLE FIRST TWO YEARS OF
THE PANDEMIC AS A BAD DREAM.
BUT AS PEOPLE OF SCIENCE WE
WOULD BE DOING A DISSERVICE TO
THE 27 MILLION PEOPLE WHO LOST
THEIR LIVES IN THE PANDEMIC,
WHOSE DEATHS ARE LABELED AS
EXCESS DEATHS.
DEFINED AS THE NUMBER OF DEATHS
IN A GIVEN COUNTRY DURING THE
PANDEMIC, MINUS THE AVERAGE
PRE-PANDEMIC DEATH RATE FOR
THAT COUNTRY.
AND THE ECONOMISTS SHOWED US
THAT ONLY A SMALL FRACTION OF
EVERYONE WHO DIED AND WHO HAD
EXCESS DEATHS ACTUALLY HAD
COVID.
THAT MEANS THERE'S A LOT OF
PEOPLE WHO ARE BY STANDERS IN A
HEALTH SYSTEM AND HEALTHCARE
SETTINGS WRECKED BY THE
PANDEMIC, HEART ATTACKS,
STROKES, ET CETERA, THAT DIED
BECAUSE OF THE PERILS OF OVER
CROWDING, WE THINK.
UNFORTUNATELY, THE U.S. RANKS
AMONGST ONE OF THE HIGHEST IN
EXCESS MORTALITY RATE DURING
THE PANDEMIC.
WHICH BEHOOVES US TO TAKE A
CLOSER LOOK WITH A MAGNIFYING
GLASS TO FIGURE OUT WHAT WE DID
WRONG AND WHAT WE CAN DO BETTER
IN THE FUTURE.
MANY OF YOU ARE AWARE HOSPITALS
WERE BURSTING AT THE SEAMS AT
SEVERAL POINTS DURING THE
PANDEMIC.
I REMEMBER BEING IN SOME OF
THESE SURGING HOSPITALS IN THE
COMMUNITY EARLY ON IN THE
PANDEMIC, AND I COULDN'T HELP
BUT NOTICE A LOT OF CRITICAL
ELEMENTS OF CLINICAL MANAGEMENT
WERE SLIPPING THROUGH THE
CRACKS.
THERE WERE JUST NOT ENOUGH
HANDS, ENOUGH EYES, ENOUGH
BRAINS TO PROVIDE THE
HIGH-PRECISION CARE WARRANTED
FOR PATIENTS WHO ARE CRITICALLY
ILL, WITH COVID-19 AND OTHER
PROBLEMS.
IT RAISED THE QUESTION IN MY
MIND DID HOSPITAL EXCESS STRAIN
DRIVE SOME OF THESE EXCESS
DEATHS.
FLAG REPRESENTS EXCESS DEATH
DURING THE PANDEMIC.
OUR HYPOTHESIS FRAMEWORK WE
BUILT WAS THAT OVER CROWDED
HOSPITALS LIKELY LEAD TO PEOPLE
NOT COMING TO THE HOSPITAL AND
DYING AT HOME.
WHEN WE HAVE EXCELLENT BACK
SCENES THAT CAME ABOUT --
VACCINES THAT CAME ABOUT AND
PEOPLE DECIDED NOT TO TAKE IT,
IT LED TO MORE PEOPLE COMING TO
THE HOSPITAL AND OCCUPYING
RESOURCES.
WE HAVE FOUR MEDIATORS WE THINK
MEDIATED THE POOR OUTCOME
RELATED TO OVER CROWDED
HOSPITALS.
ONE WAS CRITICAL SHORTAGES.
THIS IS THE DEMAND/SUPPLY
IMBALANCE BETWEEN TOO MANY
PATIENTS, TOO FEW BEDS,
EQUIPMENT, TOO FEW PERSONNEL,
EYES, HANDS, BRAINS.
WE MADE A LOT OF IMPLICIT
TRIAGE DECISIONS, THAT PROBABLY
ALSO PLAYED A ROLE.
WE WERE UNABLE TO TRANSFER
PATIENTS WHO REQUIRED VITAL
SERVICES AT OTHER HOSPITALS
THEY COULD NOT GET AT THEIR
PARENT HOSPITAL.
THAT PROBABLY PLAYED A ROLE.
AND WE HAD TO ALTER OUR CARE
STANDARDS.
THIS IS CALLED CRISIS CARE.
YOU WILL HEAR ABOUT IT MORE
DURING DR. HICKS TALK.
EARLY TRIGGER FOR COMFORT CARE,
PRACTICING OUTSIDE SCOPE AND
LIMITING RESOURCE-INTENSIVE
CARE.
I WAS FORTUNATE I AM IN THE
INTERMURAL COMMUNITY AND WE HAD
A PRE-EXISTING RELATIONSHIP
WITH SOME OF THE FEDERAL
AGENCIES WE DID WORK WITH
SEPSIS, WE LIMITED THIS TO DO
OUR INVESTIGATIONS AT WARP
SPEED.
THE CDC CAME TO US WITH BURNING
QUESTIONS THEY WERE UNABLE TO
ANSWER THAT HAD A CLINICAL TILT
THAT WE WERE ABLE TO ANSWER.
AND WE LEVERAGED THE CDC TO
BETTER MESSAGE AND COMMUNICATE
OUR FINDINGS TO THE PUBLIC.
WE HAD A PREEXISTING FRAMEWORK
OF HOW TO DO THIS RESEARCH
BASED ON OUR TRACK RECORD OF
BIG DATA INVESTIGATIONS IN THE
FIELD OF ANTIBIOTIC RESISTANCE
AND SEPSIS.
AND WE USED PRIMARILY A LARGE
DATABASE CALLED THE PREMIERE
HEALTHCARE DATABASE.
THIS COMPANY RELEASED SOMETHING
SPECIAL COVID-19 RELEASE.
SO THEY ESSENTIALLY GAVE US
DATA EVERY 15 DAYS.
THE DATA WAS AS RECENT AS THREE
WEEKS AGO.
THESE DATA COME FROM 900 U.S.
HOSPITALS AND COMBINATION OF
ADMINISTRATIVE BUT ALSO
CLINICAL DATA, LAB VALUES,
VITALS ET CETERA.
THESE DATA WERE VERY HELPFUL IN
BEING ABLE TO ANSWER QUESTIONS
USING PANDEMIC DATA IN THE
PANDEMIC.
BUT ONE OF THE CARDINAL
QUESTIONS OR CHALLENGES WE HAD
INITIALLY WAS, HOW DO WE KNOW
WHETHER THESE DATA ARE RELIABLE.
THESE DATA HAD NEVER BEEN USED
BEFORE USING OPEN CLAIMS THAT
WERE SO RECENT.
SO WE DID SOME QUALITY CONTROL
ANALYSES AND WHAT WE FOUND IS
IF WE WAITED FOR JUST TWO
MONTHS TO USE THE DATA, THAT
WAS A SWEET SPOT THAT GAVE US
THE OPTIMAL BALANCE BETWEEN
DATA ACCURACY AND RECENCY.
AND THEN ANOTHER CHALLENGE WE
HAD HOW DO WE IDENTIFY PATIENTS
WITH COVID-19 IN THESE
DATABASES.
NOT ALL DATABASES HAVE LAB DATA.
EARLY ON WE PERFORMED A STUDY
PUBLISHED IN JAHMA, A RELEASED
DIAGNOSIS CODE FOR COVID-19, WE
EVALUATED AGAINST THE GOLD
STANDARD THAT WAS PCR DATA.
WHAT WE FOUND IS THAT DIAGNOSIS
CODE WAS 95%, FOR THOSE WHO USE
THIS DATA THIS IS AN EXCELLENT
RELIABILITY YOU CAN GET FOR A
BILLING CODE FOR AN ENTITY.
PROBABLY BECAUSE COVID-19 IS
BLACK AND WHITE.
EITHER YOU HAVE IT OR DON'T
HAVE IT DEPENDING ON THE LAB
TEST.
ONE OF THE ADVANTAGES OF THIS
INVESTIGATION NOT ONLY CONVINCE
US WE COULD USE THESE DATA TO
ANSWER OUR QUESTIONS BUT WE
ALSO FELT WE VICARIOUSLY
CONTRIBUTED TO MANY OTHER
PEOPLE'S INVESTIGATIONS THAT
HUNG THEIR HAT ON OUR
VALIDATION.
OUR NEXT CHALLENGE WAS HOW DO
WE IDENTIFY THE STRAIN THAT IS
POSED BY TOO MANY PATIENTS IN
HOSPITALS?
IT IS A NEBULOUS CONCEPT.
IN THE PAST INVESTIGATORS HAVE
USED THINGS LIKE, 20% ABOVE
CAPACITY.
30% ABOVE CONSENSUS CAPACITY.
THAT ASSUMES THAT ALL PATIENTS
ARE THE SAME.
BUT THAT'S NOT TRUE.
PATIENTS MAY HAVE DIFFERENT
SEVERITY, LINKED TO DIFFERENT
RESOURCE NEEDS AND PERSONNEL
NEEDS.
SO FOR THAT REASON, WE CREATED
A NOVEL SURGE INDEX TO ELICIT
THAT.
THE NUMERATOR INCLUDES EVERYONE
WITH COVID ADMITTED TO HOSPITAL
IN A GIVEN MONTH.
EXCEPT THEY ARE WEIGHTED BY
THEIR SEVERITY LINKED TO THE
NEEDS FOR NURSING AND INCREASED
NEEDS FOR RESPIRATORY
THERAPISTS, THE TWO MOST
PRECIOUS PERSONNEL COMMODITIES
DURING THE PANDEMIC.
WE NORMALIZED THAT NUMERATOR BY
THE PRE-COVID NOMINAL BED
CAPACITY.
HOW MANY BED HOSPITAL DO YOU
HAVE.
WHAT THAT DID WAS, IT ALLOWED
US TO COMPARE STRAIN ACROSS
HOSPITALS IN THE U.S. THAT HAD
DIFFERENT BASELINE
INFRASTRUCTURE AND CAPACITY.
LET ME EXPLAIN THIS WITH AN
EXAMPLE.
LET'S ASSUME THERE ARE TWO
HOSPITALS, HOSPITAL A, BIGGER
100-BED HOSPITAL, HOSPITAL B IS
SMALLER 50-BED.
LET'S ASSUME JUNE, THE 20
PATIENTS WHO HIT THE SMALL
HOSPITAL WERE VENTILATED.
ALTHOUGH BOTH HOSPITALS HAD 20
PATIENTS HIT THE HOSPITAL AT
THE SAME TIME, THE STRAIN THAT
WAS ENCOUNTERED BY THE SECOND
SMALLER HOSPITAL WHO SAW MORE
SEVERE CASES WAS MUCH HEAVIER.
EACH CIRCLE REPRESENTS A SINGLE
HOSPITAL IN A GIVEN MONTH, AND
COLOR CODED BY REGION.
YOU COULD SEE THERE WAS A GREAT
VARIATION IN THE AMOUNT OF
STRAIN ENCOUNTERED BY DIFFERENT
HOSPITALS.
BECAUSE ON THE Y INDEX, THE
SURGE INDEX IS ON THE
LOGARITHMIC SCALE.
WE TRIED TO ACCOUNT FOR
HOSPITAL RELATED AND TIME
RELATED FACTORS TO TRY TO
UNDERSTAND BETWEEN SURGE INDEX
AND MORTALITY RISK.
MORTALITY WENT UP AS HOSPITALS
HIT HIGHER PERCENTILES.
NOT ONLY THAT, OBSERVATION IS
OBVIOUSLY MOVING.
BUT AT THE SAME TIME, IF YOU
HAVE THE TOP LAYER OF THE SURGE
INDEX WHERE YOU HAVE THE
MAXIMUM NUMBER OF PEOPLE IN THE
HOSPITAL, THERE'S A LOT OF
DEATHS, THE ABSOLUTE RISK IS
ALSO PRETTY HIGH.
WE WERE ABLE TO EVIDENCE USING
STRUCTURAL MODELS WHERE WE
FOUND A VERY MOVING STATISTIC
THAT ONE IN EVERY FOUR COVID-19
HOSPITAL DEATHS MAY HAVE BEEN
RELATED TO OVER CROWDING.
THIS WAS SORT OF A MONUMENTAL
FINDING BECAUSE IT CAME OUT
DURING THE PANDEMIC AND DELTA
VARIANCE WHERE HOSPITALS WERE
STRAINING AND IT LED TO MANY
HOSPITAL LEADERS AND MANY
PEOPLE WITHIN ASPER AND
HOSPITAL PREPAREDNESS PROGRAM
UNDERSTAND THE IMPORTANCE OF
DECOMPRESSING HOSPITALS WITH
LOAD BALANCING SO NO SINGLE
HOSPITAL WAS COMPROMISED.
OUR BOTTOM LINE IS OVER
CROWDING KILLS AND LOAD
BALANCING MIGHT SAVE LIVES.
SENIOR FELLOW IN OUR DEPARTMENT
TOOK ON THE RESPONSIBILITY
DOING A SYSTEMATIC REVIEW TO
TRY TO LOOK AT THE STUDIES THAT
COMPARED CASELOADS, STRAINS AND
OUTCOMES.
HE FOUND 39 STUDIES THAT FOUND
A DETRIMENTAL IMPACT.
I THINK THE MORE IMPORTANT
IMPACT FROM THE STUDY IS 37 OF
THE 39 STUDIES USED INDEPENDENT
UNIQUE METRICS THERE WAS NO
DATA FROM LOW INCOME COUNTRIES.
WE NEED A CONSENSUS FRAMEWORK
FOR DEFINING SURGE STRAIN TO
MONITOR, COMPARE, TRIAGE AND
MITIGATE FOR THE FUTURE.
AND IT SHOULD ALSO BE SCALABLE
TO THE DEVELOPING WORLD SO WE
CAN UNDERSTAND THE IMPACTS OF
STRAIN ON A GLOBAL SCALE.
OUR NEXT OBVIOUS QUESTION WAS,
WE FOUND THAT SURGING HOSPITALS
INCREASED MORTALITY OF THEIR
PATIENTS.
BUT WE LOOKED AT IT AT AN
AGGREGATE LEVEL.
WE KNOW HOSPITALS VARY IN THEIR
CAPABILITIES, PROVISIONS OF
CARE.
MAYBE THAT HAS AN IMPACT AND
MAYBE THE LARGER MORE EQUIPPED
HOSPITALS, CENTERS OF
EXCELLENCE ARE MAYBE MORE
RESILIENCE.
TO ASK THAT WE RAN AN
INTERACTION ANALYSIS.
WHAT WE FOUND, WHETHER YOU WERE
A SMALL OR BIG HOSPITAL,
MULTI-I.C.U. OR SINGLE I.C.U.,
ONE THAT DOES ECMO OR NO,
SURGES WERE DETRIMENTAL TO
SURVIVAL.
WHAT IT TELLS ME, WE SHOULD
PROBABLY LOAD BALANCE
ACROSS-THE-BOARD AND IN THAT
WAY, WE CAN MAKE SURE SMALL
HOSPITALS HAVE THE PROVISION TO
SEND PATIENTS THEY CAN'T TAKE
CARE OF AT OTHER HOSPITALS AND
LARGE CENTERS OF EXCELLENCE CAN
CONTINUE TO NOT BE INUNDATED BY
MUNDANE CASES AND THEY CAN
FOCUS ON THE MORE COMPLEX CASES
ONLY THEY CAN TAKE CARE OF.
SO THE BOTTOM LINE IS EARLY
DECOMPRESSION OF LARGER CENTERS
ACCEPT REFERRALS.
THE NEXT OBVIOUS QUESTION WAS,
WE FOUND THAT SURGES ARE
DETRIMENTAL.
BUT THE NEXT STEP IS WE NEED TO
MOVE THESE PATIENTS OUTSIDE.
INITIALLY NOBODY KNEW IF IT WAS
SAFE TO MOVE A COVID PATIENT
FROM ONE HOSPITAL TO THE OTHER.
ONE OF MY MENTEES WHO TRAINED
AS A STAFF CLINICIAN, SHE USED
A NATIONAL E.M.S. DATABASE TO
ASK THE QUESTION, HOW OFTEN DO
PATIENTS DECOMPENSATE DURING
GROUND OR AIR TRANSPORT IF THEY
HAVE ACUTE RESPIRATORY ILLNESS.
THIS STUDY WAS FOUND IN JAMA.
WHAT SHE FOUND, THE MORE
IMPORTANT POINT, THE RISK WAS
NO GREATER DURING THE PANDEMIC
MOVING THESE PATIENTS COMPARED
TO PRE-PANDEMIC.
THAT TOLD US PERHAPS CLINICIANS
DO A PRETTY GOOD JOB WHO GETS
MOVED AND SAFE TO MOVE.
THIS ENCOURAGED THE SENTIMENT
IN TERMS OF MOVING PATIENTS TO
OTHER HOSPITALS DURING THE
PANDEMIC.
WHILE THAT MAY BE HELPFUL IN
THEORY, CAN YOU REALLY LOAD
BALANCE WHEN ALL THE HOSPITALS
ARE INUNDATED.
TO ADDRESS THIS, DR. SARZYNSKI
USED THE PREMIER DATABASE, WERE
HOSPITALS ABLE TO FLEX THEIR
CAPABILITY MOVING PATIENTS
OUTSIDE MORE THAN THEIR
BASELINE.
WHAT YOU SEE IS A HEAT BAR AT
THE TOP.
THE MORE YELLOW, THE GREATER
THE PROPORTION OF HOSPITALS
THAT WERE SURGING.
THE TREND LINE REPRESENTS THE
CUMULATIVE TOTAL OF TRANSFERS
BETWEEN HOSPITALS FOR 600
HOSPITALS.
IN THE PRE-PANDEMIC PERIOD IT'S
PRETTY STABLE.
THE TRANSFER RATE.
AND IT FLUCTUATES DURING THE
PANDEMIC.
MOST OF THE TIME IT'S DIPPING.
THE DIPS ARE WHEN HOSPITALS ARE
SURGING MORE.
IT'S KIND OF PARADOXICAL, BUT
THERE'S A NEED DURING SURGES
BUT THERE'S LESS MOVEMENT OF
PATIENTS DURING THAT.
NOT ONLY THAT, THE BARS
REPRESENT PRE-PANDEMIC TO
PANDEMIC TRANSFERS.
WE KNOW SMALL HOSPITALS DON'T
HAVE CAPABILITIES AND THEY NEED
TO SEND PATIENTS OUTSIDE FOR
HIGHER LEVELS OF CARE.
YOU COULD SEE THE DISPARITY,
URBAN HOSPITALS WERE ABLE TO
FLEX MORE 50% BASELINE
CAPABILITIES TO TRANSFER.
RURAL WERE NOT.
IT'S COMPLETELY FLAT.
THE BOTTOM LINE, WE NEED
COUNTERMEASURES IN THE FUTURE
AGAINST TRANSFER BARRIERS IN
RURAL AREAS TO MAINTAIN CARE
ABILITY.
THE NEXT IS RELATED TO COVID
VACCINE HESITANCY.
WE WERE ON THE FRONT LINE
TAKING CARE OF PATIENTS WHO DID
EVERYTHING RIGHT.
THEY GOT FULLY VACCINATED BUT
THEY HAD UNDERLYING PROBLEMS
THAT RESULTED IN THEM NOT
MOUNTING AN IMMUNE RESPONSE.
THEIR BODY WOULD BEHAVE LIKE AN
UNVACCINATED PATIENT AND THEY
WOULD DIE.
AND OTHERS AT HOME WHO WOULDN'T
GET VACCINATED WHO POSED A RISK
TO THESE PATIENTS.
WHY IS THIS MOVEMENT NOT
HAPPENING?
WHAT WE REALIZED WAS PERHAPS WE
NEED TO SHOW PEOPLE MORE THAN
JUST THIS TRIAL IS 60%
EFFECTIVE, THIS TRIAL IS
SHOWING THIS VACCINE IS 70%
EFFECTIVE.
MAYBE THE COUNTRY ISN'T MOVED
BY THAT AND MAYBE THEY WOULD BE
MOVED BY ABSOLUTE RISK.
WE COLLABORATED WITH THE CDC
AND DID THIS NMWR LED BY
CHRISTINA YEK AND SARAH WARNER.
WHAT WE FOUND OUT OF 1.2
MILLION FULLY VACCINATED IN THE
U.S., THE RISK OF DYING WITH
BREAK THROUGH ILLNESS IS LESS
THAN 1 IN 33,000.
THIS IS A PERSON WHO WOULD MOVE
A PERSON ON THE STREET AND HAVE
THEM GO TO CVS AND GET
VACCINATED, WE THOUGHT.
WHAT HELPED IS MORE THAN 200
NEWS OUTLETS TOOK OUR FINDINGS
AND DISSEMINATED TO THE PUBLIC.
INCLUDING SOME OF THESE TOP
NEWS OUTLETS.
THE FORMER DIRECTOR OF THE CDC
RACHEL VALENSKI WENT ON AND
PROMOTED OUR MESSAGE WHICH WAS
HELPFUL.
THE ABSOLUTE LOW RISK IN A
POPULATION IS OFTEN NOT
DISCERNABLE TO THE PUBLIC IN
VACCINE TRIALS AND REAL WORLD
DATA CAN HELP FILL THAT GAP.
FINALLY, WE ASKED THE QUESTIONS
OUR PROGNOSTIC SCORES FOR
COVID-19 RELIABLE FOR TRIAGE?
WE WHO ARE WORKING ON THE FRONT
LINE IN CRITICAL CARE UNITS
WERE REALLY WORRIED THAT A
PERIOD WOULD COME WHERE WE HAVE
TWO PATIENTS AND ONE VENTILATOR
AND WE NEED TO DECIDE WHO TO
GIVE IT TO.
FORTUNATELY THAT SCENARIO
DIDN'T REALLY OCCUR IN OUR
COUNTRY.
HOWEVER, THERE WAS A LOT OF
IMPLICIT TRIAGE.
WE HAD HIGHER BARS FOR PATIENTS
TO GO TO THE I.C.U., I'M SURE
MANY SUFFERS IN THE BARGAIN.
TRIAGE ALGORITHMS HAD ALREADY
BEEN SET UP BY SEVERAL STATES.
WE WANTED TO CRITICALLY
APPRAISE WHETHER THESE ARE
RELIABLE OR NOT.
MIKE KELLER, WHAT HE FOUND WAS
FIRST OF ALL, THE SOFA SCORE,
SEQUENTIAL ORGAN FAILURE SCORE,
TO KNOW HOW SICK THEY ARE ON A
GIVEN DAY, THAT WAS A SCORE.
NOT COVID SPECIFIC, IT WAS USED
AND IMPLEMENTED IN SEVERAL
STATES, CRISIS STANDARDS OF
CARE ALGORITHM, THE ONES
COLORED IN RED.
BUT WHEN WE LOOKED IN REAL
WORLD DATA WE FOUND THE AREA
UNDER THE CURVE, THE C
STATISTIC FOR PREDICTING
MORTALITY IN INTUBATED PATIENT
IS REALLY AS GOOD AS FLIPPING A
COIN.
THERE'S A POORLY PERFORMING
METRIC USED BY MOST STATES AND
HAD WE USED THIS, WE WOULD HAVE
MISTRIAGED SO MANY PEOPLE.
NOW THE NEXT STEP WAS TO TRY TO
FIND A COVID-SPECIFIC
PROGNOSTIC SCORE, THE MODIFIED
SCORE PERFORMED WELL IN THE
FIRST WAVE.
BUT DR. YEK SHOWED IN THIS
STUDY, OVER TIME, THE COVID
SPECIFIC PROGNOSTIC SCORE
DECAYED OVERTIME TO SHOW
PREDICTABILITY.
COVID WHICH EVOLVED AND
TREATMENTS CHANGED OVER TIME
AND OUR ABILITY TO PROTECT
AGAINST THE DISEASE CHANGED
OVER TIME.
ALL THAT PROBABLY HAD AN
IMPORTANT ROLE IN CHANGING THE
ABILITY TO PREDICT MORTALITY.
SO IN THE FUTURE WE NEED TO BE
MINDFUL OF FREQUENTLY
REAPPRAISING THE ACCURACY OF
SOME OF THESE CODES.
SO IN SUMMARY, HOSPITAL OVER
CROWDING IS DETRIMENTAL TO
HOSPITAL SURVIVAL.
SCALABLE CONSENSUS DEFINITION
IS NEEDED FOR CASELOAD STRAIN.
MOVING PATIENTS BETWEEN
HOSPITALS WAS RELATIVELY STAYED
DURING THE PANDEMIC BUT
CHALLENGING AMID WIDESPREAD
SURGE.
TOOLS ARE OBSCURE AND WARRANT
REAPPRAISAL.
IN THE FUTURE WE HOPE TO
IMPROVE CARE QUALITY DURING
OUTBREAKS.
WE HOPE TO HAVE A SCALABLE
CONSENSUS OF CASELOAD STRAIN.
WE HOPE TO OPTIMIZE ON A DAILY
BASIS AND HOPE TO GENERATE
DATA-DRIVEN SOLUTIONS TO INFORM
CRITICAL HEALTHCARE LEGISLATION
AND POLICY IN DISASTER
PREPAREDNESS.
I'M VERY THANKFUL TO MY A-TEAM.
MY LAB THAT WORKED DAY AND
NIGHT DURING THE PANDEMIC TO
GET YOU THESE IMPORTANT DATA.
I NOW HAND OVER THE PODIUM TO
DR. HICK AND I WOULD BE HAPPY
TO ANSWER QUESTIONS AFTER.
[APPLAUSE]
>> John Hick: THANKS SO MUCH,
I'M JOHN HICK FROM MINNEAPOLIS.
I WANT TO THANK YOU ALL FOR
ATTENDING FOR YOUR INTEREST IN
THIS TOPIC AND FOR HAVING ME,
IT'S A PRIVILEGE.
I WILL GET STARTED WITH THIS
FIRST SLIDE, IF I MAY.
I WILL TAKE A BIT OF A POLICY
TURN ON, THIS I WANT TO THANK
SAMEER FOR PROVIDING SCIENTIFIC
BASIS TO CONFIRM ANECDOTALLY
WHAT WE KNEW TO BE TRUE ON THE
GROUND BUT ALSO REINFORCE SOME
OF THE THINGS THAT NEEDED TO BE
REINFORCED, LIKE ESSENTIALLY
LACK OF UTILITY OF SOFA SCORES
IN PREDICTING OUTCOME.
I FEEL A BIT GUILTY, IT WAS ONE
OF MY INITIAL ARTICLES THAT
DROVE THE STATE OF UTAH TO RELY
ALMOST EXCLUSIVELY ON SOFA
SCORES.
TO THE DETRIMENT OF THOSE
TRIAGE PROTOCOLS.
I'M SPEAKING ON MY BEHALF
TODAY, NOT ON ANY AGENCY OR MY
EMPLOYER'S BEHALF.
THIS IS THE CONVENTIONAL
CONTINGENCY IN CRISIS FRAMEWORK
WE USE WHEN WE THINK HOW A
SURGE IS AFFECTING OUR CLINICAL
CARE.
IN CONVENTION IT'S USUAL STUFF.
CONTINGENCY THEY DON'T POSE
SUBSTANTIAL RISK OF OUTCOME TO
A PATIENT.
CRISIS WE ARE CROSSING A
BOUNDARY WHERE THERE IS
SUBSTANTIAL RISK.
THIS SOUNDS BLACK AND WHITE,
LIKE WE SWITCH ON THE LIGHT AND
WE GO TO CRISIS STANDARD OF
CARE PLANS.
WHAT COVID REALLY TOLD US WAS,
IT'S NOT THAT CLEAR.
THAT DISTINCTION IS FOGGY AT
TIMES.
A LOT OF CENTERS OF CARE FOR
WORK WAS FOCUSED OF BINARY
RESOURCES YOU CAN'T DIVIDE OR
ALLOCATE IN NON VERSUS ZERO
WAYS.
SOFA SCORES WERE A CONTRIBUTOR
TO THAT.
IT ASSUMED IT WOULD BE A CLEAR
POINT WHICH WE WOULD GO INTO
CRISIS.
IT RELIED A LOT ON TRIAGE TEAMS
TO MAKE ALLOCATIONS OF THESE
BINARY RESOURCES.
AND ASSUMED WE COULD IMPLEMENT
ETHICAL IDEALS JUSTLY.
THAT TURNED OUT TO BE PROBABLY
NOT TRUE.
WE HAD TO MAKE COMPROMISES NO
MATTER WHAT WE TRIED TO DO,
DESPITE OUR BEST INTENTIONS.
SO WE ARE PRESENTED ON ALMOST A
DAILY BASIS WITH QUESTIONS
ABOUT WHEN DO WE ACTUALLY CROSS
THAT LINE INTO CRISIS.
WAS THE ABSENCE OF, IN MANY
CASES THE CHEMO THERAPEUTICS
DEPENDENT ON PLATINUM, A LOT OF
PATIENT IT'S WAS.
THEY WEREN'T ABLE TO GET THEIR
USUAL CANCER TREATMENTS BECAUSE
OF THE LAGS.
WHAT DO WE DO FROM A LEGAL
PROTECTIONS AND REGULATORY AND
OTHER STANDPOINT AND DEVELOPING
CONSISTENT GUIDANCE.
DRUG SHORTAGE WAS SO PERVASIVE
FOR ME, EVERY MONDAY I GET A
COLOR CODED CHART THAT SHOWS
WHICH OF THE DRUGS ARE IN
SHORTAGE.
IT BECOMES PART OF THE ROUTINE
BUT WE HAVE TO BE CAREFUL TO
THINK THROUGH THOSE RISKS, THAT
REALLY IS POSING A RISK IN A
LOT OF SITUATIONS TO PATIENTS.
P.P.E. SHORTAGE, STAFFING
SHORTAGES POSED QUESTIONS ABOUT
CRISIS CENTERS OF CARE FOR
CAREGIVERS, AT WHAT POINT DO WE
PUT CAREGIVERS AT SUBSTANTIAL
RISK AT THE BEDSIDE.
I THINK WE NEED TO THINK MORE
OF CRISIS STANDARD OF CARE AS A
TOOLBOX.
USING CLINICAL TOOLS, LEGAL AND
REGULATORY FRAMEWORKS AND OTHER
THINGS TO BEST ADAPT TO THE
CIRCUMSTANCES AT HAND.
THOSE CIRCUMSTANCES VERY, VERY
RARELY AS SAMEER SAID INCLUDE A
TRIAGE OF VEPT LATORS.
OR VENTILATORS.
LIKE CIRCUIT BREAKERS WE WANT
THE SYSTEM TO GRACEFULLY
DEGRADE.
WE DON'T WANT THE SYSTEM TO
JUST STOP PROVIDING CARE.
WE WANT TO HAVE PROGRAMMED
ADAPTATIONS ALONG THE WAY THAT
MINIMIZE THE RISK ACROSS THAT
SPECTRUM TO THE CARE PROVIDER
AS WELL AS TO THE PATIENTS.
SOME KEY ISSUES THAT CAME UP
DURING COVID-19, THE MORAL
DISTRESS AND ISSUES THAT WERE
RISING AT THE BEDSIDE WITH
ALLOCATION OF RESOURCES WEREN'T
PERCEIVED OR SHARED AT THE
CORPORATE LEVELS.
THE CEO'S AND OTHERS, I THINK,
DIDN'T WANT TO WILLFULLY
PORTRAY THE BEDSIDE CLINICIANS
BEING OUT OF TOUCH.
BUT THERE WAS SUCH A PRESSURE
TO MAINTAIN PROCEDURES BECAUSE
OF THE DURATION OF THE EVENT,
THE ABILITY TO RECOGNIZE CRISIS
AND SAY WE WERE IN THAT KNOWING
THAT MIGHT TRIGGER FURTHER
RESTRICTIONS ON SURGERIES AND
ELECTIVE PROCEDURES WAS A HILL
NO ONE WAS WILLING TO MOUNT.
BUT IT DID LEAD TO A REALLY
SIGNIFICANT DISCREPANCY AND
WHAT IT WAS AT THE BEDSIDE
VERSUS BOARD ROOM.
WE SAW A LOT OF ACCESS TO CARE
ISSUES.
EARLY ON IN THE URBAN AREAS,
HOSPITALS IN NEW YORK CITY,
LIKE ELMHURST.
SURGE WAS HIGHER THAN OTHER
HOSPITALS IN THE AREA.
LATER ON IN THE PANDEMIC, WE
SAW RURAL FACILITIES NO MATTER
WHAT THEY TRIED COULD NOT GET
TERTIARY CENTERS TO ACCEPT
PATIENTS, HIGH POTASSIUM LEVELS
FROM LACK OF DIALYSIS.
A LOT OF AD HOC DECISIONS WERE
MADE.
WE HAD A SURVEY OF CLINICIANS
IN MINNESOTA AND SOME OF THE
MOST POIGNANT CAME FROM RURAL
FACILITIES.
I WAKE UP AT 4:00 EVERY
MORNING, I'M NOT SURE I HAVE
THE ENERGY TO TALK TO A FAMILY
TO MAKE THEIR PATIENT D.N.R.
BECAUSE WE DON'T HAVE THE
RESOURCES.
IT'S NOT SOMETHING WE SHOULD
PUT ON THE FAMILIES OR
CLINICIANS AT THE BEDSIDE.
BUT THERE WAS A FAILURE ACROSS
THE URBAN HOSPITALS, EVEN
WITHIN HOSPITALS, A LOT OF
TIMES IT SEEMED THE RISK WE
WERE RUNNING IN THE EMERGENCY
DEPARTMENT WAS SUBSTANTIALLY
DIFFERENT THAN WHAT THE RISK
WAS UPSTAIRS BECAUSE THEY COULD
CONTROL THE FLOW AND WE COULD
NOT.
ALSO I THINK WE NEED TO THINK
CAREFULLY ABOUT WHAT ASPECTS OF
CRISIS CARE PLANS ARE SEPARATE
FROM DAILY PLANS.
INTEGRATION OF THOSE I THINK IS
REALLY IMPORTANT.
WHAT DO YOU DO WHEN YOU COME UP
WITH A REALLY NICE PROCESS.
DISTRIBUTION OF MONOCLONAL
ANTIBODIES.
ONE STATE SAID THEY WEREN'T
GOING TO PARTICIPATE.
MAINTAINING ACCESS AND EQUITY
WHEN SOME SYSTEMS ARE OPTING
OUT AND THERE'S NO REGULATORY
OR LEGAL WAY TO FORCE THEM TO
PARTICIPATE.
TRIAGE TEAMS IN THE END I THINK
PROVED PRETTY CUMBERSOME AND
NOT NEEDED FOR MOST OF THE
DECISIONS MADE.
SO HOW DO WE ADAPT THAT INTO
FUTURE ITERATIONS OF OUR CRISIS
PLANNING?
AS SAMEER MENTIONED SOFA WAS
VALIDATED IN A MULTI-ORGAN
FAILURE COHORT, BUT IT DOESN'T
IDENTIFY WELL IN RESPIRATORY
FAILURE.
MANY HAVE ACUTE RENAL
INSUFFICIENT.
AND EVERYONE THOUGHT THEY WERE
SPECIAL.
THIS WAS SOMETHING WE RAN
ACROSS AT THE STATE LEVEL,
WHETHER MONOCLONAL OR VACCINES,
EVERY GROUP FELT THEY SHOULD
HAVE SPECIAL QUALIFICATIONS OR
SPECIAL ACCESS TO SERVICES.
YOU KNOW, TRYING TO DEFINE IN
ADVANCE OF AN EVENT NEXT TIME
WHO SHOULD QUALIFY FOR SPECIAL
ACCESS, VERSUS NOT, I THINK
WILL BE VERY IMPORTANT IN
MANAGING SOME OF THAT NOISE.
SO I REALLY WANT TO FOCUS A LOT
OF OUR EFFORTS GOING FORWARD
AVOIDING CRISIS.
AS SAMEER MENTIONED LOAD
BALANCING IS ONE OF THOSE KEY
THINGS, REGIONAL CONSTRUCTS FOR
SHARING WE ARE TRYING TO DO THE
SAME CLINICAL ADAPTATION AND
ANTICIPATING BETTER.
AT THE END OF THE DAY YOU CAN
DO THREE THINGS, BRING A
RESOURCE IN, MOVE A PATIENT OUT
OR TRIAGE THE RESOURCES YOU
HAVE.
WE DON'T WANT TO GET TO THE
LAST POINT VERY OFTEN.
THIS IS DATA FROM NEW YORK.
WHEN NEW YORK CITY WAS
PARTICULARLY OVERWHELMED, YOU
COULD SEE THIS AREA OF VERY
BRIGHT YELLOW HERE, OVER 90% OF
AVERAGE I.C.U. OCCUPANCY.
EVEN AROUND THAT, UP IN
CONNECTICUT AND OTHER AREAS
THERE WERE TERTIARY CENTERS
CLOSE BY AND WE WEREN'T USING
THEM.
IT'S TO FULLY UTILIZE THE
RESOURCES WITHIN A GIVEN AREA.
WE TRIED TO DO THAT IN
MINNESOTA, THROUGH THE CRITICAL
CARE COORDINATION CENTER.
AS YOU CAN SEE, WE TOOK ABOUT
5,000 REQUESTS FOR TRANSFERS.
WE WERE ABLE TO PLACE 1800
PATIENTS.
I THINK WE DID A GOOD JOB
CONSIDERING THE RESOURCES WE
HAD AVAILABLE.
AND THIS WAS PUBLISHED, YOU
COULD SEE IN THE METRO THERE
WERE A LOT OF TRANSFERS BUT
SOME OF THE MOST REMOTE
HOSPITALS LIKE THE ONE ON
CANADIAN BORDER INTERNATIONAL
FALLS, SOME OF THE PLACE THAT'S
TRANSFERRED THE MOST CRITICALLY
ILL PATIENTS INTO OUR TERTIARY
CENTERS.
MAKING SURE THE NEEDS GET MET
THROUGH SYSTEMS LIKE THIS,
THROUGH OUR C-4, SO WE CAN MOVE
THE RIGHT PATIENTS TO THE RIGHT
PLACE AT THE RIGHT TIME IS HUGE.
THAT HAS TO INVOLVE
PRIORITIZATION, TO MAKE SURE
THE PATIENTS WHO HAVE THE
HIGHEST RISK OF DEATH OR
CRITICALLY ILL OR PRIORITIZED
FOR THE TERTIARY CENTERS BUT
ALSO MAKE USE OF ALL OF THE
I.C.U. BEDS IN THE STATE.
WHEN I ASK HOSPITALS HOW MANY
I.C.U. BEDS THEY HAVE, THEY MAY
BE TALKING ABOUT A TELEBED,
MONITORED BED, OR CAPABLE OF
MECHANICAL VENTILATION BUT NOT
DIALYSIS CAPABILITY.
OR ECMO CAPABILITY.
HOW DO WE MAXIMIZE USE OF ALL
OF THOSE AND MAKE SURE PATIENTS
WHO SIMPLY NEED MECHANICAL
VENTILATION CAN BE CARED FOR IN
AN URBAN HOSPITAL, WHILE
PRESERVING TERTIARY FOR THE
MOST ILL AND MOST COMPLEX.
WE HAVE TO THINK OF TRIAGE A
LITTLE DIFFERENTLY.
EVERYBODY GETS UPSET ABOUT THE
IDEA OF EXPLICIT TRIAGE WHEN WE
SAY THIS PERSON PROBABLY
SHOULDN'T BE RECEIVING THE
RESOURCES THEY ARE RECEIVING AT
THIS POINT.
THE TRADE OFF WE RELY ON
IMPLICIT TRIAGE, AD HOC AT THE
BEDSIDE BY A PROVIDER.
THERE ARE OTHER BIASES THAT
CREEP INTO THOSE DECISIONS WE
WANT TO TRY OUR BEST TO
ELIMINATE.
ACCESS TRIAGE AS WE MENTIONED,
CAN YOU ACCESS THE SERVICES YOU
NEED.
THAT WAS A HUGE ISSUE DURING
COVID AND HONESTLY CONTINUES TO
BE AN ISSUE IN RURAL UNITED
STATES, PARTICULARLY RIGHT NOW.
WE ARE THINKING FOR THE MOST
PART ABOUT TERTIARY TRIAGE,
PROACTIVE TRIAGE AFTER WE HAVE
STARTED DEFINITIVE TREATMENT.
NOT TALKING ABOUT PRIMARY
TRIAGE WHEN THEY FIRST HIT THE
EMERGENCY DEPARTMENT AFTER A
MASS CASUALTY INCIDENT OR AFTER
A CT OR OTHER THINGS.
WHEN DO WE ASSESS THE PATIENT
AND DETERMINE WE CAN'T CONTINUE
TO PROVIDE THE RESOURCES?
WHEN WE MAKE DECISIONS LIKE
THIS, THE OFFICE OF CIVIL
RIGHTS HAS BASICALLY INSTRUCTED
AN INDIVIDUALIZED PATIENT
ASSESSMENT BE DONE.
WE SHOULDN'T BE CONSIDERING AGE
AS AN INDEPENDENT OR GENERAL
FACTOR, RACE, WE SHOULD BE
CONCERNING THE DIAGNOSIS,
UNDERLYING DISEASE STATES.
WHAT IT MEANS TO THAT PATIENT
AS AN INDIVIDUAL AND WHAT IS
THE CHANCE OF BENEFIT FROM THE
SERVICES WE WOULD LIKE TO TRY
TO PROVIDE.
IN THE PAST WE THOUGHT ABOUT
THIS FROM WHO BENEFITS MOST, I
THINK WE NEED TO REORIENTED WHO
SUFFERS THE LEAST WHEN WE DON'T
OFFER A THERAPY.
WHO IS RECEIVING NON-BENEFICIAL
TREATMENTS RIGHT NOW.
BECAUSE ALL OF US COULD
PROBABLY GO THROUGH I.C.U.'S
AND IDENTIFY PATIENTS WHO DON'T
HAVE A REASONABLE CHANCE MAKING
IT OUT OF THAT INTENSIVE CARE
UNIT.
THERE'S AN AWFUL LOT OF
POTENTIAL SOCIAL FACTORS
PROPOSED BEING INCLUDED IN
TRIAGE ALGORITHMS.
WE NEED TO BE EXTRAORDINARILY
CAREFUL ABOUT DOING THAT.
I DON'T HAVE THE TIME TO GO
INTO DETAILS NOW.
WE NEED TO HONE OUR PROGNOSTIC
CAPABILITY FIRST AND THINK HOW
AND WHEN THOSE CONSIDERATIONS
COME IN AND MAKE SURE WE AS
CLINICIANS AREN'T TRYING TO
SOLVE POPULATION-BASED PROBLEMS
AT THE BEDSIDE.
THE NOT WHAT WE DO AND NOT WHAT
WE SHOULD BE DOING.
THE FOCUS NOT ON THE TRIAGE OR
VENTILATORS AS MUCH AS REGIONAL
CONSISTENCY.
ARE WE TRYING TO DO THE SAME
THING NO MATTER WHAT THE SIZE
OF THE HOSPITAL IS WITH THE
RESOURCES WE HAVE AVAILABLE.
THERE'S THREE BASIC PARTS OF
THE EQUATION THAT GO IN, EXCUSE
ME, I'M REALLY SORRY.
THERE'S THREE BASIC PARTS OF
THE EQUATION WHAT CONSTITUTES
CARE.
THE TIME WE SPEND DEVOTED TO
THE CARE.
THE AMOUNT OF TIME SOMEONE WILL
USE A RESOURCE LIKE A
VENTILATOR.
IT'S THE TREATER RESOURCES.
THE TREATMENT RESOURCES, THE
INTENSITY OF THE LEVEL OF
TREATMENT.
THE EXPERTISE, THE RESOURCES
AND AMOUNT OF TIME COME
TOGETHER.
THE MILITARY HAS DONE A REALLY
NICE JOB PARSING OUT SOME OF
THESE DISTINCTIONS I THINK WE
CAN CONTINUE TO GO FURTHER WITH.
THE TOURNIQUET THERE IS AN
EXAMPLE, WHAT IS THE OPTIMAL
BALANCE.
IF YOU WANT THE MINIMAL AMOUNT
OF TIME, MINIMAL AMOUNT OF
TREATMENT, MAXIMUM BENEFIT.
AT THE PROVIDER LEVEL, I DON'T
EXPECT YOU TO READ THIS
GRAPHIC, BUT THE A FIGURE TAKEN
FROM A JOURNAL, THE JOINT
COMMISSION THIS IS OPEN SOURCE,
CONSIDERATIONS AS THE DECISIONS
BECOME MORE WEIGHTY FOR THE
PATIENT, AS THEY AFFECT THEIR
OUTCOME MORE, WE SHOULD BE MUCH
MORE CAREFUL WITH THOSE.
EMPHASIZING CONSULTATIONS WHEN
IT'S OUTSIDE YOUR USUAL SCOPE
OF PRACTICE.
AND MAKING SURE WE DO HAVE A
TRIAGE TEAM OR NUMEROUS EYES ON
A DECISION REMOVING SOMEONE
FROM MECHANICAL VENTILATION
AGAINST THE WISHES OF
THEMSELVES OR AGAINST THE
FAMILY WISHES.
WE NEED TO ALSO MAKE SURE
PROVIDERS ARE SUPPORTED.
I SAW WAY TOO MANY INSTANCES
WHICH THE PROVIDERS WERE
SADDLED WITH DECISIONS AND
MORAL INJURY DURING COVID-19 I
DON'T EVER WANT TO SEE REPEATED.
THE CHANCE OF BURN OUT.
THE CHANCE OF MORAL DISTRESS IS
VERY, VERY HIGH IN THESE
CIRCUMSTANCES WHEN WE CAN'T
PRACTICE WE KNOW WE SHOULD BE
CAPABLE OF PRACTICES.
WE HAVE TO MAKE SURE OUR
PROVIDER SUPPORT IS BETTER NEXT
TIME AROUND.
LEGAL PROTECTIONS FOR PROVIDERS
ARE INCREDIBLY IMPORTANT.
I THINK AGAIN SOMETHING WE HAVE
TO BE ABLE TO DEMONSTRATE WE
ARE PUTTING OURSELVES IN LEGAL
JEOPARDY WHEN MAKING ANY OF
THESE DECISIONS OR PROVIDING
IN-PLACE CARE WE DON'T HAVE
DIRECT RESPONSIBILITY FOR.
THIS HAS COME UP NUMEROUS TIMES
AS AN EXAMPLE WHEN CRITICAL
CARE OR OTHER PROVIDERS ARE
VERY COMFORTABLE CONTINUING TO
PROVIDE ADVICE AND SUPPORT FOR
PATIENTS BEING PROVIDED FOR IN
A HOSPITAL THEY WON'T HAVE
RESPONSIBILITY FOR.
SO CRISIS CONDITIONS EXISTED IN
48 STATES.
I DON'T DOUBT THEY EXISTED IN
OREGON AND IOWA BUT WE COULDN'T
DOCUMENT THAT.
BUT OF THOSE STATES VERY FEW
IMPLEMENTED ANY LEGAL
STRATEGIES TO PROTECT PROVIDERS
THAT WERE MAKING DECISIONS.
SOME OF THOSE DID ENACT LEGAL
PROTECTIONS BUT SOME WERE ONLY
FOR COVID PATIENTS.
AND IN SOME CASES THOSE LEGAL
PROTECTIONS WERE PUT IN PLACE
AT THE START OF THE PANDEMIC
AND ESSENTIALLY PROVIDED ANY
PROVIDER DECISION, THAT'S
RISKY, THAT'S OVER BROAD AND WE
DON'T NEED THAT LEVEL OF
PROTECTION.
IF ANY OF OUR ALLOCATION
DECISIONS WILL BE SUCCESSFUL,
WHEN THEY GET DOWN TO
NON-BENEFICIAL TREATMENT, WE
WILL HAVE TO HAVE SOME DEGREE
OF IMMUNITY AND INDEMNIFICATION.
THERE WAS A HOSPITAL IN A
SUBURB A PATIENT WITH COVID
RELATED LUNG INJURY WHO WASN'T
GOING TO SURVIVE.
QUESTIONS TO SAY THIS PATIENT'S
CARE WAS FUTILE AND SUPPORTS
SHOULD BE WITHDRAWN, THE FAMILY
OBJECTED AND GOT A RESTRAINING
ORDER PREVENTING REMOVING THE
VENTILATOR.
ACROSS THE TIME THAT INDIVIDUAL
WAS IN THE I.C.U. AT MERCY, WE
HAD HUNDREDS OF PATIENTS WHO
COULD HAVE BENEFITED FROM THOSE
SERVICES.
IF WE ARE GOING TO DO THIS
RIGHT WE HAVE TO HAVE SOME
PROTECTION FOR THESE DECISIONS.
THIS IS JUST AN EXTREME
EXAMPLE, THIS PATIENT'S CARE
WAS CLEARLY FUTILE, HE WAS
FINALLY TRANSFERRED, THEY FOUND
A LOCATION TO ACCEPT HIM, HE
EXPIRED A FEW DAYS AFTER
ARRIVING THERE.
VERY UNFORTUNATE SITUATION.
FURTHER THE MORAL INJURY AND
DISTRESS EXPERIENCED BY THE
C.M.O. AND PROVIDERS OF THE
HOSPITAL WERE UNPRECEDENTED.
THEIR HOMES WERE VANDALIZING,
THE SOCIAL MEDIA CAMPAIGNS
AGAINST THEM WERE UNRELENTING,
FOR TRYING TO DO THE RIGHT
THING NOT ONLY FOR THIS PATIENT
BUT THE POPULATION.
LOOKING AT THE FOUR S'S,
SPECIAL CONSIDERATIONS AND
SUPPLIES.
DO WE HAVE THE RIGHT P.P.E.
THIS IS THE BASIS FOR LOOKING
AT CONTINGENCIES ACROSS THE
CONTINUUM OF CARE.
STATE OF MINNESOTA PUBLISHED
WHAT DO YOU DO IF YOU DON'T
HAVE ENOUGH OXYGEN.
THIS BECAME A VERY PRESSING
SITUATION IN HOSPITALS DURING
COVID BECAUSE OF THE HIGH FLOW
UTILITIES WE WERE USING.
TO THE POINT SOME HOSPITALS HAD
TO USE TEMPORARY OXYGEN
PROVISION PIPE, THROUGH
WINDOWS, THEY HAD TO HAVE
SPRINKLERS ON THE VAPORIZORS TO
KEEP THEM FROM ICING OVER.
IT'S NO SURPRISE WHEN YOU MAP
THAT S-DOMAIN AGAINST THE
DIAGRAM HERE THAT CMS USES TO
LOOK AT ROOT CAUSE ANALYSES FOR
POOR OUTCOMES, IT'S THE SAME
FACTORS.
SAMEER AND I HAVE REALLY
THOUGHT ABOUT THIS, IN CONTEXT
OF, THIS IS NOT A DISASTER
PROBLEM.
THIS IS A PATIENT SAFETY
PROBLEM.
DISASTERS UNMASK THE WEAKNESSES
IN OUR CARE DELIVERY SYSTEM AND
ALLOW US TO SEE WHERE THE
PROBLEMS ARE.
WE HAD A UNIQUE OPPORTUNITY TO
DO THAT WITH COVID AND WE HAVE
IT GOING FORWARD.
THE SCIENCE TERM, RELATIVELY
LIMITED.
BECAUSE EVEN THOUGH THESE
BUCKETS SEEM THEY ARE THE RIGHT
BUCKETS OF THE CARE AND OVERALL
SENSE THAT IS DELIVERED, WE
DON'T YET UNDERSTAND WHERE THE
RISKS ARE.
SO BACK YEARS AGO WHEN WE WERE
LOOKING AT CARDIAC ARREST, THE
EPSTEIN CONSENSUS CONFERENCE
WHAT'S PUT TOGETHER IN NORWAY.
THEY BASICALLY CAME OUT WITH
THIS IS HOW WE WILL DEFINE THE
TIME INTERVALS, THESE ARE THE
DEFINITIONS WE WILL APPLY TO
CARDIAC ARREST.
THIS IS THE CHAIN OF SURVIVAL
WE WILL SEE BETWEEN THE
APPLICATION OF SCIENCE, THE
EDUCATION, THE LOCAL
IMPLEMENTATION OF THOSE THINGS
EQUALING SURVIVAL.
I THINK IT'S EXACTLY THE SAME
KIND OF THINK WE NEED TO THINK
ABOUT APPLYING TO THE SCIENCE
OF SURGE, AS WE TRY TO PLUG THE
HOLES IN THE SWISS CHEESE,
SYSTEMS FAILURE THAT LEADS TO
POOR OUTCOMES.
BUT IDENTIFYING THOSE PROBLEMS
IS THE NEXT STEP THAT SAMEER'S
DATA AND OTHERS LEADS US TO.
WHAT GOING FORWARD DO WE WANT
TO KNOW.
AND WHAT AS RESEARCHERS AND
CLINICIANS CONTRIBUTE TO
IMPROVEMENT IN THESE
PROCESSESMENT WITHIN A HOSPITAL
YOU HAVE A FINITE AMOUNT OF
SPACE.
BASED ON THE LOADS AND THE
SPACE AVAILABLE, WHAT ARE THE
BEST PLACES TO PUT PEOPLE?
WHO ARE THE BEST CARE
DELIVERERS, YOU KNOW, FROM A
TRAINING STANDPOINT, FROM A
HIERARCHY OF CARE STANDPOINT.
WHEN WE DELIVER CARE USING
NON-TRADITIONAL STAFFING MODELS
WHAT DOES THAT MEAN?
IS IT BETTER TO DO THAT OR
LENGTHEN.
WHAT IMPLICATIONS DOES FATIGUE
HAVE TO COGNITIVE LOAD.
SOME MAY VARY BY TIME OF DAY, I
WORK STRAIGHT NIGHT SHIFTS, I
KNOW COGNITIVELY I'M NOT THE
SAME AS NIGHT AS I AM DURING
THE DAY.
THE E.H.R.'S ARE FULL OF DATA
RIGHT NOW.
WE HAVE NO SHORTAGE OF DATA BUT
WE HAVE A SHORTAGE OF
APPLICATION SCHEMES WE CAN TAKE
AND TRY TO APPLY TO THAT AND
MAKE MEANINGFUL ANALYSES AND
LEAD TO MEANINGFUL OUTCOMES.
BUT THE DATA IS OMNI PRESENT.
THE AMOUNT OF DATA FED BY
E.H.R.'S INTO DIGITAL LAKES
RIGHT NOW FOR MULTIPLE VARIED
PURPOSES, UNFORTUNATELY NONE OF
THEM ALLOW RESPONSE BY A.I.
DRIVEN TOOLS TO FIGURE OUT WHAT
PREEXISTING FACTORS PUT YOU AT
HIGHEST RISK, WHAT MEDICATIONS
MIGHT BE MOST PROTECTIVE AND
EFFECTIVE FOR TREATMENT.
THERE ARE SO MANY OBLIGATIONS
AS PAYERS, ON CMS, ON
GOVERNMENT, ON THE PRIVATE
SECTOR, ON US AS PATIENTS AND
CLINICIANS TO FIGURE OUT HOW WE
USE THIS DATA IN A LOT MORE
EFFICIENT WAY AND MAKE IT
AVAILABLE SO WE CAN ANALYZE IT
DURING TIMES OF ESPECIALLY DEM
EC AND CRISIS.
EITHER DEATH REPORTS NEED TO BE
STANDARDIZE.
IF YOU DIE FROM SECONDARY
EFFECTS OF A HURRICANE, THAT'S
NOT COUNTED AS A HURRICANE
DEATH AND IN FLORIDA IT IS.
WE DON'T EVEN AGREE ON WHAT
DISASTER DEATHS MEAN ACROSS THE
UNITED STATES.
WE NEED TO DO A LOT MORE WORK
ON SURVIVABILITY MODELS.
THERE'S NO REASON WITH TOOLS
AVAILABLE AND THE DATA
AVAILABLE WE CAN'T
SIGNIFICANTLY IMPROVE OUR
PROGNOSTICATION, I CAN'T STAND
THE FACT WHEN I WATCH PLAYOFF
FOOTBALL I CAN BE TOLD EXACTLY
SUCCESSFUL CONVERSION OF A
FOURTH DOWN IS, BUT WHEN
SOMEONE AT THE BEDSIDE ASKS ME
WHAT THE PROBABILITY OF THEIR
LOVED ONES DYING, I CAN'T GIVE
MORE THAN A BALLPARK.
WE NEED TO MANAGE END OF LIFE
DECISIONS IN THE U.S.
I WON'T DWELL ON THAT HERE.
BUT WE HAVE SO MANY
OPPORTUNITIES TO FIGURE OUT HOW
TO BETTER SERVE OUR AT-RISK
COMMUNITIES, TREATMENT,
ASSESSMENTS, INTEGRATING
DEVICES AS WE MOVE FORWARD.
BOTH PERSONAL DEVICES WHETHER
YOUR SMART WATCH OR ACTUAL
BIOMEDICAL DEVICES TO LET THEM
DO THINGS INDEPENDENT WITHIN
PARAMETERS SET BY THE
CLINICIANS TO REDUCE WORK
FATIGUE, AMONG OTHER THINGS.
ON THE STAFF SIDE, WE NEED TO
FIGURE OUT WHERE THE STAFF
COULD BE BEST USE, THEIR
EXPERTISE COULD BE BEST USED
AND IF THAT LACK OF EXPERTISE
IS CONTRIBUTING SUBSTANTIALLY
TO DEATH.
IT PROBABLY IS.
BUT WE NEED TO DEFINE THAT.
IS IT IN THE I.C.U. OR THE
FLOOR, PEOPLE ARE BEING PUSHED
OUT OF I.C.U. TO FLOOR CARE.
FIGURING OUT ERRORS THAT LEAD
TO POOR OUTCOMES IS PARAMOUNT
TO FIXING THOSE ERRORS AND WE
NEED TO EXPERIENCE WITH
DIFFERENT STAFFING MODELS TO
FIGURE OUT WHICH POSE THE
LOWEST RISK.
THE LOAD BALANCING STRATEGIES
WE ARE DISCUSSING THERE'S STILL
WORK TO BE DONE THERE.
PROOF OF CONCEPT, WE NEED TO
PROVE THIS COULD BE DONE AND WE
NEED TO DEMONSTRATE IT'S
ESSENTIALLY AN OBLIGATION WHEN
WE ARE FACED WITH HOSPITALS
THAT ARE OVER LOADED AND OTHER
HOSPITALS IN THE AREA THAT ARE
NOT.
DEFINING THAT EXCESS MORTALITY
BETTER AND STATES USING THESE
LOAD BALANCING PROCEDURES
EFFECTIVELY.
HAVING TRIGGERS WHEN WE GET TO
THRESHOLDS.
IT'S NON LINEAR AS HOSPITALS
INCREASE DEMAND AND INCREASE
CASELOADS.
WHICH IS THE POINT WE WILL
TRIGGER LOAD BALANCING AND HOW
DO WE MAKE SURE THE HOSPITALS
ARE OBLIGATED TO COOPERATE EVEN
BETWEEN HEALTHCARE SYSTEMS AND
FIGURING OUT PLATFORMS TO DO
THIS.
I DON'T FORESEE A GOVERNMENT
PLATFORM BEING ESTABLISHED ANY
TIME SOON.
DATA IS ONE THING, ANALYTICS
AND USE OF THE DATA ARE OTHER
THINGS WE NEED TO CONTINUE TO
WORK ON.
THERE'S A LOT OF SOLUTIONS
AHEAD.
TECHNOLOGY OFFERS A LOT OF
SOLUTIONS TO IMPROVE OUR
CLINICAL WORKFLOW AT THE
BEDSIDE.
INFORMATICS OFFERS US BOTH DATA
TO BOTH FORWARD AND FOSTER
THOSE SOLUTIONS BUT ALSO GIVES
US DATA TO WORK WITH ON PATIENT
PLACEMENT, SO OUR COORDINATION
CENTERS CAN GET PEOPLE TO THE
RIGHT PLACE AT THE RIGHT TIME
FOR TREATMENT.
AGAIN, BRINGING UP THE FACT
THESE SCARCITY DRIVEN ISSUE
THEZ REFLECT PATIENT SAFETY
ISSUES ON A DAILY BASIS.
THIS ISN'T JUST ABOUT DISASTERS.
WHAT WE LEARN FROM THESE
SITUATIONS CAN HELP INFORM
BETTER PATIENT CARE ON A DAILY
BASIS AND DRIVE RESEARCH THAT
CAN FURTHER PATIENT SAFETY,
HOPEFULLY THAT WILL DRIVE
REGULATORY CHANGE, THAT WILL
DRIVE REIMBURSEMENT CHANGES FOR
PREPAREDNESS FOR SURGE EVENTS
WHICH WE DON'T CURRENTLY HAVE.
A COUPLE RESOURCE ARTICLES.
PERSPECTIVES PIECE NATIONAL
ACADEMIES OF MEDICINE.
WHAT DID WE LEARN ABOUT CRISIS
CENTERS OF CARE DURING COVID
AND HOW DOES THAT NEED TO
CHANGE GOING FORWARD.
THE JOINT COMMISSION I
MENTIONED FOCUSED ON CLINICIANS
AT A HOSPITAL WHEN FACED WITH
EXCESS DEMANDS.
SO ALLOCATIONS ARE JUST AND
FAIR.
BOTH ARE OPEN ACCESS AND
HOPEFULLY WILL BE HELPFUL IF
YOU ARE INTERESTED A LITTLE
MORE ON THE POLICY SIDES AND
FUTURE LOOKING SIDES OF THIS
CONVERSATION.
AGAIN, THAT'S A LOT IN A LITTLE
BIT OF TIME.
I GENUINELY APPRECIATE YOUR
INTEREST IN THE TOPIC AND YOUR
TIME TODAY AND THE INVITATION
TO COME SPEAK.
I WILL TURN IT BACK TO HENRY
FOR QUESTIONS.
>> THANK YOU, JOHN.
TWO PERSPECTIVES, WE USUALLY
DON'T GET INTO.
ONE IS FROM A POPULATION
MEDICINE POINT OF VIEW THAT
SAMEER PRESENTED.
AND THE OTHER IS FROM A
DISASTER MANAGEMENT PERSPECTIVE.
BUT BEFORE WE TAKE A FEW
QUESTIONS, LET ME ASK SAMEER
AND JOHN, IF YOU ARE A
CLINICIAN IN MARYLAND, MARYLAND
HAD A UNIQUE SYSTEM FOR DEALING
WITH THIS.
CAN YOU DESCRIBE VERY BRIEFLY.
IF YOU WERE A CLINICIAN AT ONE
OF THE HOSPITALS, HOW DID YOU
TRIAGE PATIENTS IN MARYLAND AND
HOW THAT WORKED, IF YOU COULD
SAY IN 90 SECONDS OR LESS, AND
JOHN CAN MAYBE TALK ABOUT
MINNESOTA.
>> THANK YOU, HENRY, FOR THE
QUESTION.
IT'S A DIFFICULT QUESTION TO
ANSWER.
BECAUSE WE ARE NOT TALKING
ABOUT ONE POINT IN TIME.
AND NOT TALKING ABOUT ONE TYPE
OF HOSPITAL.
MARYLAND, AS YOU KNOW, IS A
DIVERSE SET OF HOSPITALS IN
TERMS OF THEIR CAPABILITIES.
AND IN TERMS OF THE SERVICE
THAT'S WERE PROVIDED DURING THE
PANDEMIC.
AND YOU KNOW, DURING THE COURSE
OF THE PANDEMIC, MARYLAND
DEVELOPED A TRANSFER
COORDINATION CENTER, THAT
REALLY DID A GOOD JOB BASED ON
MY CONVERSATIONS WITH PEOPLE IN
THE LEADERSHIP AT THIS CENTER,
THEY WERE ABLE TO ACTUALLY
PLACE ABOUT 70-75% OF THE CALLS
THAT THEY GOT.
THEY WERE ABLE TO PROVIDE
ADVICE FOR CARE IN PLACE FOR
THE REST OF THEM.
I THINK IF YOU LOOK AT IT, I
THINK YOU WANT TO LOOK AT IT
NOT ONLY FROM ONE STATE'S
PERSPECTIVE BUT IN COMPARISON
TO REST OF THE COUNTRY.
DIFFERENT STATES DID ZHIFRNGS.
DIFFERENT THINGS.
THERE WERE SOME STATES NOT ABLE
TO GET THAT LEVEL OF SUCCESS.
I THINK MARYLAND HAS A LOT TO
OFFER LESSONS FOR OTHER STATES
IN THE FUTURE WE COULD LEARN
FROM.
TO SPECIFICALLY ANSWER YOUR
QUESTION, IF I WAS A PHYSICIAN,
I ENCOUNTERED SITUATIONS WHERE
I COULD NOT ACCEPT A PATIENT
WHO NEEDED CONTINUOUS RENAL
REPLACEMENT THERAPY BECAUSE
ONLY I COULD PROVIDE IT AT MY
I.C.U.
IT WAS DISTRESSING.
THIS IS ONE ANECDOTE, BUT JUST
IMAGINE, ONE PHYSICIAN IN THE
I.C.U. AND THERE ARE SO MANY.
AND THERE WERE SO MANY SUCH
SCENARIOS, COLLECTIVELY
POPULATION SCIENCE REALLY HELPS
TO CAPTURE THE BREADTH OF THIS
DISTRESS.
>> SAMEER, AT LEAST IN MARYLAND
YOU HAD A PHONE NUMBER YOU
COULD CALL, EMERGENCY
MANAGEMENT SERVICE THAT'S WOULD
HAVE COORDINATED THAT FOR YOU.
I GUESS THAT'S PART OF WHAT YOU
WORKED AT ALSO.
HOW DID THAT WORK IN MINNESOTA,
JOHN, IF YOU WERE A CLINICIAN
IN A COMMUNITY HOSPITAL?
>> GREAT QUESTION, FIRST
REFLECTING ON MARYLAND, THEY
HAVE A LONG HISTORY OF
CENTRALIZED E.M.S. AND WAS ABLE
TO BUILD OFF THAT IN A VERY
SUCCESSFUL WAY.
DAVE MARCOSY AND KALYN HAD
TRIGGERS WHEN WE ENTER CRISIS
OF CARE, NEW ENGLAND JOURNAL OF
MEDICINE A LITTLE WHILE AGO.
FRAMEWORK THAT COULD PROBABLY
BE APPLIED NATIONALLY, HOW DO
WE ALL AGREE WHEN WE HIT THAT
TIPPING POINT.
I THINK WHAT CLINICIANS ASKED
FOR IS MORE ABILITY TO COMPEL
TRANSFERS WHEN A PATIENT WAS
CLEARLY NOT RECEIVING EMERGENCY
CARE THEY NEEDED BECAUSE THE
HOSPITAL THEY WERE IN COULDN'T
PROVIDE IT, WHETHER TRAUMA
CARE, DIALYSIS, WHATEVER, TO
HAVE A STANDARDIZED PROCESS FOR
MANAGING.
WHETHER ALTERNATING BETWEEN
TERTIARY CENTERS OR SOME OTHER
WAY TO MANAGE THAT PATIENT WHO
IS VERY, VERY HIGH PRIORITY.
AND JUST A RECOGNITION WE ARE
ALL IN THIS TOGETHER.
YOU ARE MAKING TOUGH CHOICES.
WE WILL MAINTAIN THAT AND
CONTINUE FOR CONSISTENCY.
PATIENTS WERE BEING PUT AT RISK
AND DYING.
WE DIDN'T SEE A REFLECTION OF
THAT OUTWARD, PARTIALLY THEY
DIDN'T WANT TO ADMIT THINGS
WERE THAT BAD.
SAME PROCESS, THE TOLL FREE
NUMBER YOU CALLED, EARLY ON IN
THE PANDEMIC IT WORKED REALLY
WELL, WE PLACED 100% OF
PATIENTS AFTER THE EMERGENCY
DECLARATION WENT AWAY AND THERE
WAS NO WAY TO COMPEL
PARTICIPATION IN THAT, OUR
ABILITY TO PLACE THOSE TRANSFER
PATIENTS FELL OFF PRECIPITOUSLY.
MUCH TO CORRECT GOING FORWARD
POLICY-WISE.
>> ANY OTHER QUESTIONS HERE?
TOM BERKLOW HAS QUESTIONS.
>> A COMMENT FIRST.
ACTUALLY, FIELD MARSHAL HELMET
-- IN THE 1800'S SAID
SOMETHING TO PARAPHRASE HIM
THAT NO PLAN SURVIVES FIRST
CONTACT WITH THE ENEMY.
I THINK IN EFFECT THAT'S A
LITTLE BIT OF WHAT WE SAW.
DISAPPOINTINGLY THE PLANS THAT
WE HAD IN PLACE HOW WE ARE
GOING TO ADDRESS SOME SORT OF
DISASTER OF THIS GLOBAL NATURE
REALLY PROVED INADEQUATE.
I GUESS FOR ME, BECAUSE I'M NOT
INVOLVED IN THIS SPACE, YOU
KNOW, THERE WERE LESSONS
LEARNED.
AND I APPRECIATE YOUR BOTH
EXCELLENT PRESENTATIONS AND
PUTTING A SPOTLIGHT ON YOUR
WORK AND THE HEROIC EFFORTS YOU
PUT INTO TRYING TO ADDRESS THIS.
WE HAVE A VERY DECENTRALIZED
HEALTHCARE SYSTEM IN OUR
COUNTRY.
THAT ALLOWS FLEXIBILITY, BUT
ALSO, I THINK IT KEPT US
FROMING HAVE MORE UNIFIED
RESPONSES.
AS WE GO FORWARD, I DO WORRY
THAT WE ARE LOSING SIGHT OF
SOME OF THE LESSONS LEARNED.
FROM Y'ALL'S PERSPECTIVE, WHAT
ARE THE FORMS, IT SEEMS THIS
HAS TO BE ADDRESSED AT THE
STATE HEALTH LEVELS.
ARE THERE FORUMS OR GATHERINGS
THEY ARE SHARING TO GET BACK TO
THEIR STATE LEGISLATURES?
>> WE SHOULD TAKE THAT AND
ORGANIZE ONE OF THEM.
>> A COUPLE THINGS.
ONE IS WE ARE TRYING TO
PRESERVE THESE LESSONS LEARN
AND AUGMENT IMPLEMENTATION.
ONE WAY IS WE HAVE A VIRTUAL
CONFERENCE.
ASPR TRACY, GATEWAY FOR
EMERGENCY PREPAREDNESS.
WE ARE HOSTING A TWO DAY
MEDICAL CONFERENCE FOR MEDICAL
DIRECTORS COMING UP IN FEBRUARY.
SO THOSE INDIVIDUALS WHO ARE
DIRECTORS OF THEIR E.M.S.
SERVICES OR THE STATE LEVEL CAN
COME TOGETHER AND TRY TO
CONTINUE TO WORK TOGETHER TO
PROBLEM SOLVE AND MOVE THIS
FORWARD.
I WILL SAY SOME OF THE
SOLUTIONS LIKE THE MOCKS
FEATURE VERY HEAVILY IN THE
UPCOMING FIVE-YEAR HEALTHCARE
CAPABILITIES FOR THE NATION,
THAT ASPR WILL BE PUTTING OUT
HERE IN THE NEXT FEW MONTHS.
THOSE WILL BE INTEGRATED IN THE
HOSPITAL PREPAREDNESS
REQUIREMENTS GOING FORWARD.
I THINK YOU ARE LIKELY TO SEE
MORE TRACTION ON MOX.
I'M HOPEFUL AS WE ARE PREPARED
TO RAISE THESE PATIENT SAFETY
ISSUES, CMS AND REGULATORS WILL
LOOK MORE CLOSELY AND WILL BE
MUCH MORE INTERESTED IN HELPING
US COLLECT THE OPERATIONAL DATA
THAT INDICATES WHEN HOSPITALS
ARE OVER THEIR USUAL CAPACITY
AND CONTRIBUTE TO LOAD
BALANCING SOLUTIONS.
I HOPE THERE'S A MULTI-PRONGED
FOCUS TO TRY TO TAKE THOSE
LESSONS AND TRY TO BOTH WITHIN
POLICY AND PROGRAM MAKE SURE WE
ARE CAPTURING SOME OF THOSE
ISSUES.
>> JOHN, NOW THAT YOU ARE
WORKING IN HEALTH AND HUMAN
SERVICES, DO YOU THINK THEN
THERE WOULD BE MORE FINANCING
FOR DISASTER PREPAREDNESS AND
PUTTING SYSTEMS IN PLACE THAT
ARE ACTUALLY READY TO GO WHEN
THE DISASTER UNEXPECTEDLY
OCCURS?
>> I HOPE SO.
I THINK A GOOD MODEL IS WITH
DIALYSIS.
THERE'S A FEW PENNIES FOR EVERY
DIALYSIS PATIENTS PERFORMED
THAT HAVE TO GO TO DIALYSIS
PREPAREDNESS.
THAT'S BEEN AN INCREDIBLY
SUCCESSFUL MODEL, ONE OF THE
REASONS WE SEE DIALYSIS THE WAY
IT IS WITHIN THE UNITED STATES,
I THINK THERE'S PRECEDENT THERE.
I ALSO THINK THERE'S A DEFINITE
NEED FOR METRICS FOR
PREPAREDNESS, WITH HOSPITALS.
A LOT OF THE REQUIREMENTS JOINT
COMMISSION AND OTHER REGULATORS
HAVE AROUND PROCESS.
DO YOU HAVE A COMMITTEE?
DO YOU HAVE SOMETHING ELSE.
I THINK TRYING TO DRILL DOWN TO
METRICS AND HOLDING HOSPITALS
ACCOUNTABLE FOR CERTAIN
CAPACITIES OF EXPANSION BOTH OF
STAFF AND SPACE WILL BE REALLY
CRITICAL GOING FORWARD.
>> THANK YOU, JOHN.
I WOULD LIKE TO ADD TO WHAT YOU
ASKED, TOM.
I THINK PART OF THE PROBLEM, WE
NEED TO TAKE OWNERSHIP OF WHAT
WE DID WRONG.
PART OF THE PROCESS OF GETTING
MORE PEOPLE TO THE TABLE TO
MAKE ACTIONABLE DECISIONS
TOGETHER FOR THE FUTURE AND IN
REAL-TIME WHEN SOMETHING LIKE
THIS HAPPENS AGAIN IS PEOPLE
SHOULD PUBLISH MISHAPPENS.
MISHAPS AND PUBLISH SYSTEM
THAT'S DIDN'T WORK.
THERE'S A PUBLICATION BIAS
ALSO, OF PROVIDING SUCCESS
STORIES OF HOW THINGS WORKED
AND THERE'S NOT THAT MUCH
MOVEMENT AFTER THAT IN TERMS OF
ACTION.
>> YEAH.
>> I THINK THE FINAL WORD SINCE
THE HOUR IS UP, IS NIH CAN
CLEARLY MAKE A CONTRIBUTION IN
TERMS OF DATA ANALYSIS THAT
INFORMS POLICY.
I THINK ONE OF THE POSITIVE
THINGS THAT CAME OUT OF THIS,
IS NIH, CDC, FDA, THE ASSISTANT
SECRETARY FOR PREPAREDNESS ARE
TALKING MORE AMONGST EACH
OTHER, TALKING MORE WITH THE
STATES.
THE HOPE IS THAT IS NOT GOING
TO DIE OFF, THAT WILL CONTINUE.
AGAIN, I THINK THIS WAS A GREAT
GRAND ROUNDS AND THANK YOU,
JOHN, FOR COMING FROM MINNESOTA
AND THANKS, SAMEER.
THANK YOU.
[APPLAUSE]