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Avera VP of Clinical Quality on COVID-19 Response

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NPR
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Dr. David Basel is Vice President of Clinical Quality with Avera Medical Group. He talked with SDPB's Jackie Hendry about the system's COVID-19 response and addressed concerns about hospital capacity. 

This interview was recorded on Monday 9/28/20.

  Jackie Hendry:

Dr. Basel, of course you know a lot of this conversation is around hospital capacity. The average everyday person before COVID probably never spared much of a thought to their local hospital's capacity. But of course, now these are unusual times, there's a lot of talk on social media about the Sioux Falls hospitals in particular. Walk us through, for the average person, when we're talking about hospital capacity, that's not just a flat number. What all do we include in conversations about hospital capacity?

Dr. Basel:

The way we think about hospitals capacity is very fluid, and from the standpoint that we probably have a hundred admits and discharges on any given day. It's a big logistical puzzle every single day way before COVID ever started. What patients are going to be leaving from the hospital on any given day, and then trying to predict scheduled surgeries, unscheduled illnesses, emergencies, everything that's coming in. Every day that is part of the process is figuring out who's coming in, and who's going out, and making sure that we have rooms for them to go to of the appropriate level of care. Even going back well before COVID, it wasn't uncommon for us to come close to having somebody in most every bed, at least temporarily. But we knew that, we would have 50 discharges that day, and so it might take an hour or two that somebody down in the ED until that room opens up. We have a whole transfer center that helps manage all of those ins and outs to make sure that it's as efficient as possible.

Jackie Hendry:

I know when we talk about Avera, we're talking about 37 hospitals, five different states, not just Sioux falls, of course. Can you talk about how your team is leveraging all those multiple locations, and what maybe triggers when a patient is either transferred or deferred to another location?

Dr. Basel:

Certainly. We look at all 37 of those hospitals as providing good high-quality care, and very similar care. They share the same electronic medical records, they share the same radiology systems, so that we can share information back and forth. For example, it's not at all uncommon for a physician whose, say, spouse gets a job in another city to move between our cities, and they can pick up right where they were with almost no disruption in practice, exactly the same way they were. I can think of one physician that practiced for a while in Yankton and then moved to Pierre for a few years. Then spouse got a job, and then she moved to Sioux Falls, and it was very similar experience and provided the same sort of care in those different places. The big difference between locations between our hospitals is what level of specialty services they have in that community.

Certainly, some of our smaller communities, whereas it would be totally comfortable and we'd be totally comfortable with them caring for bread and butter things like pneumonia, might not have access to a neurosurgeon. That's somebody came in with head trauma that we would need to transfer to a level of higher care where they would have the ability to have neurosurgery, if that's so indicated. Part of that logistics challenge is making sure that people are cared for as close to home as we can while still giving them the appropriate level of care and access to whatever resources they need. Sometimes even we will send somebody to a larger hospital if they need some of those specialty level of services. Then when they no longer need those services, that issue is resolved, and maybe they're getting closer to being more rehabilitation, and stuff like that. Our preference is always to try to get them back home, closer to home, whenever possible. Especially before for COVID when visitors and things like that. A lot more convenient for family to do it closer to home, and so that's part of the puzzle as well, it's a constant dance.

Jackie Hendry:

Right, and that makes a lot of sense. I talked with an Avera patient who’s from De Smet, ended up being airlifted to Marshall, Minnesota, because there wasn't particular room for his particular needs in Sioux Falls at the time. It sounds like, just like you said, it's a constant moving puzzle piece that just happened to be the way it was that particular day. On another day, maybe there would have been space for him in Sioux Falls. Does that sound about right? It's all about what's available that day and the particular needs of the particular patient?

Dr. Basel:

Yep, and we try to keep them at the level of as close to home as we can, and getting the appropriate level and complexity of care that they need. That doesn't surprise me that we would have somebody go somewhere else other than Sioux Falls, as long as their levels of needs are being built. I suppose it looks a little strange from the outside that that crossed the state line. But it wouldn't even enter into our mind, it's more the level of complexity of care provided at any given facility, rather than the county border, or state border, or anything like that. We've spent 25 years trying to standardize things across our hospitals as much as possible, so that things like that are as seamless as we can get them.

Jackie Hendry:

Remind folks, Avera's put out a statement, you've had surge plans in place since this all started. Remind listeners some of the aspects of that surge planning? What's included in that?

Dr. Basel:

Going clear back to the March, April time frame, when this was really ramping up and we were very concerned that we might get more patients than we could handle at a given time. We put into place action, I guess, surge plans that had been under development going clear back to pandemic flu years, 10 years before that. Those were all initiated and gave us a chance to practice our surge plans. They go everything from facility items such as, okay, we're running short on this type of bed, maybe it's an ICU bed. How do we open up and convert a post-anesthesia care unit into an ICU unit? Very similar sorts of beds and things, and so can we open up more ICU beds? To how do we shift staff resources around from maybe nurses that used to do oncology care are now staffing that ICU unit. The nurses that are used to caring for very sick people, and would be very comfortable in a medical ICU setting.

There's all sorts of kind of gradated steps as we can adjust to what the needs of the day are. In one way, we're sitting in really good shape from that standpoint today, because we had that experience in April where all of those were implemented, and a lot of preparations went into play. Now we've got a lot of folks with lots of confidence that, "Oh, I did this just a few months ago. This will be very easy if needed." We haven't had to implement hardly any of those measures at this point, but they're all fresh in our mind if the need arises.

Jackie Hendry:

Right, can you talk a little bit about what would trigger some of those steps in that plan?

Dr. Basel:

Yeah, so it does get to be a resource need. One of the other nice things that we've had early on, back in that March, April time frame. We really didn't know a lot about caring about COVID, about how much of an infection risk it would be, how effective our PPE, our masks, and face shields, and gowns, and everything would be. Early on, we cared for most of those patients at just at a couple of different hospitals. Over time, we've learned, boy, it really works well the mask, the face shields. There's been very little, if any, spread between healthcare workers and patients, or vice versa. Also, learned a lot of techniques and disseminated them about best practices for managing COVID patients, such as dexamethasone, and how much oxygen to give them, how much fluids to give them, all of these different things.

Those over time, as a lot of our different hospitals have gotten more and more cases of COVID, they've gotten a lot more comfortable. Whereas earlier in the spring, we might not have had a very large number of people that had experience and were comfortable caring for COVID, now we have quite a few people that are. We're able to shift around between regions, and regions are more comfortable with keeping patients that otherwise early on they might not have been comfortable keeping. That's given us a lot more flexibility within this standpoint. Now, probably one of the biggest threats that might make us go into a surge type of capacity is if we started losing staff to getting exposed and catching the virus actually in the community setting. Because it's almost unheard of for them to get it in the hospital setting.

The few cases we do see is because one member of a team has gotten it, and then at say a break room, or a lunchroom has let their guard down, and several people have been eating at the same table, and then spread it to each other, and we lose several staff members that way. We've had to look at some of those policies to make sure that we're staying safe outside of the standard traditional hospital environment. But it's more so, I think the risk is coming. Many of us have children that are in school right now, and so if we get it at home, it's a lot more likely. But if we started losing a significant number of staff from community transfer, I think that would be when we might have to really start looking at some of surge steps a little bit, if we had difficulty staffing the beds.

One of our ongoing asks of our own employees, and we try to get the word out again and again to other businesses, and schools, and everything. Probably that first step that everybody can help to keep all of the businesses open, including ours, is keeping all of our employees from catching this is if you have any degree of symptoms, please stay home and don't go to work. Because the symptoms from COVID in an otherwise healthy individual can be quite mild. Very much similar to the common cold on the mild cases. Whereas before we were all kind of training ourselves to fight through a cold and continue working. Now it's trying to change that perception to, "This could be COVID, I need to not expose others and get myself tested." That's the big shift that's going to help us all stay open.

Jackie Hendry:

Right, so what I'm hearing from that is, as it stands now, do you have adequate staff?

Dr. Basel:

Yeah, we're pretty comfortable right now. Actually, the number of COVID patients that we have in the Sioux Falls area has been pretty constant for about a month. Our numbers in the Sioux Falls area hasn't really gone up. We've seen it go up all across the rest of the state, but across the rest of the state is where we had the most capacity. Probably because we had so many hospitals in each little community, and so that's been a lot easier to absorb than it would have been if say all of those were in Sioux Falls, like they were early on.

Jackie Hendry:

I know in the governor's Back to Normal Plan from a few months ago, one of the recommendations in that plan calls on hospitals to reserve 30% of their beds for COVID patients as part of that surge preparation. Is that something that Avera has met or even exceeded?

Dr. Basel:

I would say we could, as part of our surge planning, we could free up 50% of our beds if we needed to, or even more. Again, it's a step wise surge process, so we can open as many beds as we need to and flex up and down as we need to. Yeah, that number doesn't scare me.

Jackie Hendry:

As of today, would you say you have 30% of beds reserved for COVID patients?

Dr. Basel:

I would say system wide the number of COVID patients is much below that, just because there's not that many COVID patients out there. No, the number is much lower than that today, just because there's not the need for it.

Jackie Hendry:

Okay, a lot of what I think has driven some of the concern that I'm seeing across social media, and this is statewide, is we see governor Noem pointing to the state's low hospitalization rate of COVID patients. She said for months that hospitalization is really the key metric to watch. I know that Mayor TenHaken has said something similar in the Sioux Falls realm. The Secretary of Health says, "We have plenty of capacity in the state." The Department of Health only reports an aggregate. Earlier today, we had a doctor from Monument on air talking about how statewide capacity isn't especially useful for the everyday person. I guess, really my key question for you is, if local hospital capacity isn't reported and is not the full picture, what makes statewide hospital capacity useful?

Dr. Basel:

I would say I'm used to taking a look only within the Avera numbers. I mainly look at the Avera numbers other than the statewide numbers, but they're very similar and they tend to track the statewide numbers when have looked at those. There's sub units of that overall capacity, one of the bigger things that I watch is also that ICU number of beds, because that is not that appropriate level of care. Because if you've got a lot of floor beds, but all of a sudden you've got a bunch of patients that need ventilators and an ICUs, those are ones that can get short of supply sooner.

Again, at least at our Sioux Falls hospital, the number of beds taken up by COVID patients and ventilated COVID patients is actually down from a few weeks ago. It's staying steady to even decreasing a little bit. What we are seeing probably causing more of a problem for us is all of the delayed care that we've had as people have been scared to come into the healthcare systems because COVID is out there. We've seen a definite trend towards a delay of care. Whereas we used to see patients come in and say for testing the first signs of chest pain, now we're seeing patients waiting a couple of days and not coming in until they're really sick with a full-blown heart attack.

Even coming in even sicker, and so we've seen part of the word that we need to get out there is that it is safe in the hospital setting. All of the infection control processes that work just wonderfully. We do need you to come in at that first sign of stroke, at that first sign of heart attack so that you don't get sicker. Because certainly from a clinical standpoint, it's so important to get in on an individual basis. But from public health standpoint, that's actually harder on the system when people are waiting like that. Because that requires longer length of stays if they wait a couple of days, and so it's really important to get in earlier.

Jackie Hendry:

Yeah. Can you explain why Avera doesn't plan to report local hospital capacity numbers?

Dr. Basel:

I would say that if everybody gives a little bit different numbers to that, it gets really confusing in our opinion, from the public standpoint, to try to piece all of that together. It makes a lot more sense to us to report it up to the state, and let the state report out one number globally. Because then if there's multiple voices giving slightly different definitions of... Well what is a hospital bed? Is it a staff bed? Is it a physical bed? If every system, every hospital, is giving a slightly different viewpoint of what that is, it gets really confusing even to us really quickly. It's just a lot more streamlined, a lot less confusing, from standpoint, if we report those up to the state, then let them report it in the aggregate that way.

Jackie Hendry:

Okay, so it's not necessarily proprietary information sort of thing, it's a matter of public confusion? This is a choice that Avera is making to not make that locally available and send to the state.

Dr. Basel:

It's also, it's a timing thing because this is such a fluid piece of information. How many beds do we have filled? Again, we're admitting a hundred and discharging a hundred every day. The answer at 2:00 PM is going to be different from the 3:00 PM, and the 4:00 PM number. The meaningfulness of that number is not a lot of times what the public thinks that is. Putting them all together in aggregate at the same time of day makes a lot of sense too.

Jackie Hendry:

Okay, I don't mean to be difficult. I'm just, I'm imagining the responses that I'll get to this and I can really understand how quickly this information changes alters how meaningful that information is. To me, the obvious response is, "Well, how meaningful is it to me in Sioux Falls if I know that there are 100 ICU beds somewhere scattered in South Dakota?" Should the everyday South Dakotan really be keeping an eye on statewide hospital capacity, or is there something else that everyday folks need to be watching when we see those numbers update every day?

Dr. Basel:

I think if you look at the trends of those numbers over time, that's going to give you a pretty good indication, probably even a better indication than the absolute number of beds. I think that's true on a lot of these types of COVID statistics, if we don't get caught up in the absolute numbers. Because again, what goes into the denominator? What goes into the numerator? It can get really complex sometimes, but if we watch that trend over time, I think that may be the easiest way to follow what is happening. Are things increasing? Are things decreasing? It's like the percent positivity numbers of the testing. What does a percent positivity rate of 13% in the state this week really mean?

That number in of itself doesn't necessarily have value unless you know last week that number was 12 and a half. Okay, that got a little bit worse this week. That's where the value of that number is. I would say, that's the same sort of thing that you would pay attention to for the hospital numbers. Maybe a thousand beds available in the state doesn't mean that much, but if you know that last week that number was 1100 then, aha, there's a hundred less than there were less week. If you knew last week that number was the other direction, then that tells you something. I'd pay attention more to trends than I would to the absolute numbers.

Jackie Hendry:

Okay, that makes a lot of sense. Thank you for spelling that out for me. Dr. Basel, that's all the questions I had for you, you've been really generous with your time. Is there anything else that you want to emphasize, or really want to make sure we touch on? The floor is yours before I let you go.

Dr. Basel:

Yeah, so a couple key points here to finish up with. Right now, certainly Avera, we're pretty comfortable with where we are from a capacity standpoint. There's no doubt that the number of hospitalizations overall has increased versus where it was a few weeks ago, but we're still pretty comfortable today. What could make us become not uncomfortable is the future, because hospital beds are not unlimited. There could come a time where we start hitting up against a limit, and how do we keep from getting there? Is a couple of things that the public can really continue to help us with. First off, get your flu shots.

If we had a flu surge on top of a COVID surge, that could be really problematic. If everybody can step up and get their flu shot this year, and keep the rates of flu down just as low as possible, that will really help us as we move into the fall. Also, like I talked about, if you can not ignore minor symptoms and get checked out to make sure that you're not an asymptomatic or minimally symptomatic spreader of COVID. Get tested, that would be really helpful to us. Then the usual things that we're talking about, good social distancing, and hand hygiene, and all of that would be very helpful. That's going to make the difference on whether all of us are able to keep the economy open and all of our businesses running.

Jackie Hendry:

Dr. Basel, I feel much better informed. I know a lot of people are going to feel that way. Thank you so much for taking the time to talk with me today, I really appreciate it.

Dr. Basel:

All right, thank you.