California Hospitals Face Surge With Proven Fixes And Some Hail Marys

KFF Health News, April 2, 2020

Nothing has prepared California's hospitals for a crisis of the magnitude facing them today.

This article was first published on Thursday, April 2, 2020 in Kaiser Health News.

By Angela Hart and Anna Maria

California's hospitals thought they were ready for the next big disaster.

They've retrofitted their buildings to withstand a major earthquake and  whisked patients out of danger during deadly wildfires. They've kept patients alive with backup generators amid sweeping power shutoffs and trained their staff to thwart would-be shooters.

But nothing has prepared them for a crisis of the magnitude facing hospitals today.

"We're in a battle with an unseen enemy, and we have to be fully mobilized in a way that's never been seen in our careers," said Dr. Stephen Parodi, an infectious disease expert for Kaiser Permanente in California. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

As California enters the most critical period in the state's battle against COVID-19, the state's 416 hospitals — big and small, public and private — are scrambling to build the capacity needed for an onslaught of critically ill patients.

Hospitals from Los Angeles to San Jose are already seeing a steady increase in patients infected by the virus, and so far, hospital officials say they have enough space to treat them. But they also issued a dire warning: What happens over the next four to six weeks will determine whether the experience of California overall looks more like that of New York, which has seen an explosion of hospitalizations and deaths, or like that of the San Francisco Bay Area, which has so far managed to prevent a major spike in new infections, hospitalizations and death.

Some of their preparations share common themes: Postpone elective surgeries. Make greater use of telemedicine to limit face-to-face contact. Erect tents outside to care for less critical patients. Add beds — hospital by hospital, a few dozen at a time — to spaces like cafeterias, operating rooms and decommissioned wings.

But by necessity — because of shortages of testing, ventilators, personal protective equipment and even doctors and nurses — they're also trying creative and sometimes untried strategies to bolster their readiness and increase their capacity.

In San Diego, hospitals may use college dormitories as alternative care sites. A large public hospital in Los Angeles is turning to 3D printing to manufacture ventilator parts. And in hard-hit Santa Clara County, with a population of nearly 2 million, public and private hospitals have joined forces to alleviate pressure on local hospitals by caring for patients at the Santa Clara Convention Center.

Yet some hospitals acknowledge that, despite their efforts, they may end up having to park patients in hallways.

"The need in this pandemic is so different and so extraordinary and so big that a hospital's typical surge plan will be insufficient for what we're dealing with in this state and across the nation," said Carmela Coyle, president and CEO of the California Hospital Association.

Across the U.S., more than 213,000 cases of COVID-19 have been confirmed, and at least 4,750 people have died. California accounts for more than 9,400 cases and at least 199 deaths.

Health officials and hospital administrators are singling out April as the most consequential month in California's effort to combat a steep increase in new infections. State Health and Human Services Secretary Mark Ghaly said Wednesday that the number of hospitalizations is expected to peak in mid-May.

Gov. Gavin Newsom said there were 1,855 COVID-19 cases in hospitals Wednesday, a number that had tripled in six days, and 774 patients in critical care. By mid-May, the number of critical care patients is expected to climb to 27,000, he said.

Newsom said the state needs nearly 70,000 more hospital beds, bringing its overall capacity to more than 140,000 — both inside hospitals and also at alternative care sites like convention centers. The state also needs 10,000 more ventilators than it normally has to aid the crush of patients needing help to breathe, he said, and so far has acquired fewer than half.

Newsom and state health officials worked with the Trump administration to bring a naval hospital ship to the Port of Los Angeles, where it is already treating patients not infected with the novel coronavirus. The state is working with the Army Corps of Engineers to deploy eight mobile field hospitals, including one in Santa Clara County. And it is bringing hospitals back online that were shuttered or slated to close, including one each in Daly City, Los Angeles, Long Beach and Costa Mesa.

The governor is also drafting a plan to make greater use of hotels and motels and nursing homes to house patients, if needed.

But the size of the surge that hits hospitals depends on how well the public follows social distancing and stay-at-home orders, said Newsom and hospital administrators. "This is not just about health care providers caring for the sick," said Dr. Steve Lockhart, the chief medical officer of Sutter Health, which has 22 hospitals across Northern California.

While hospitals welcomed the state assistance, they're also undertaking dramatic measures to prepare on their own.

"I'm genuinely very worried, and it scares me that so many people are still out there doing business as usual," said Chris Van Gorder, CEO of Scripps Health, a system with five major hospitals in San Diego County. "It wouldn't take a lot to overwhelm us."

Internal projections show the hospital system could need 8,000 beds by June, he said. It has 1,200.

In addition to taking precautions to protect its health care workers — such as using baby monitors to observe patients without risking infection — it is working with area colleges to use dorm rooms as hospital rooms for patients with mild cases of COVID-19, among other efforts, he said.

"Honestly, I think we should have been better prepared than we are," Van Gorder said. "But hospitals cannot take on this burden themselves."

Van Gorder and other hospital administrators say a continued shortage of COVID-19 tests has hampered their response — because they still don't know exactly which patients have the virus — as has the chronic underfunding of public health infrastructure.

Kaiser Permanente wants to double the capacity of its 36 California hospitals, Parodi said. It is also working with the garment industry to manufacture face masks, and eyeing hotel rooms for less critical patients.

Harbor-UCLA Medical Center, a 425-bed safety-net hospital in Los Angeles, is working to increase its capacity by 200%, said Dr. Anish Mahajan, the hospital's chief medical officer.

Harbor-UCLA is using 3D printers to produce ventilator piping equipped to serve two patients per machine. And in March it transformed a new emergency wing into an intensive care unit for COVID-19 patients.

"This was a shocking thing to do," Mahajan said of the unprecedented move to create extra space.

He said some measures are untested, but hospitals across the state are facing extreme pressure to do whatever they can to meet their greatest needs.

In March, Stanford Hospital in the San Francisco Bay Area launched a massive telemedicine overhaul of its emergency department to reduce the number of employees who interact with patients in person. This is the first time the hospital has used telemedicine like this, said Dr. Ryan Ribeira, an emergency physician who spearheaded the project.

Stanford also did some soul-searching, thinking about which of its staff might be at highest risk if they catch COVID-19, and has assigned them to parts of the hospital with no coronavirus patients or areas dedicated to telemedicine. "These are people that we might have otherwise had to drop off the schedule," Ribeira said.

Nearby, several San Francisco hospitals that were previously competitors have joined forces to create a dedicated COVID-19 floor at Saint Francis Memorial Hospital with four dozen critical care beds.

The city currently has 1,300 beds, including 200 ICU beds. If the number of patients surges as it has in New York, officials anticipate needing 5,000 additional beds.

But the San Francisco Bay Area hasn't yet seen the expected surge. UCSF Health had 15 inpatients with COVID-19 Tuesday. Zuckerberg San Francisco General Hospital and Trauma Center had 18 inpatients with the disease Wednesday.

While hospital officials are cautiously optimistic that local and state stay-at-home orders have worked to slow the spread of the virus, they are still preparing for what could be a major increase in admissions.

"The next two weeks is when we're really going to see the surge," said San Francisco General CEO Susan Ehrlich. "We're preparing for the worst but hoping for the best."

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Angela Hart: ahart@kff.org, @ahartreports

Anna Maria Barry-Jester: annab@kff.org, @annabarryjester

COVID-19 Bonanza: Stimulus Hands Health Industry Billions Not Directly Related To Pandemic

KFF Health News, March 30, 2020

Health care businesses will get billions of dollars in additional funding not directly related to the pandemic, because Congress agreed to reverse scheduled cuts in the rates paid by Medicaid and Medicare.

This article was first published on Monday, March 30, 2020 in Kaiser Health News.

By Fred Schulte

The coronavirus stimulus package Congress rushed out last week to help the nation's hospitals and health care networks hands the industry billions of dollars in windfall subsidies and other spending that has little to do with defeating the COVID-19 pandemic.

The $2 trillion legislation, which President Donald Trump signed Friday, includes more than $100 billion in emergency funds to compensate hospitals and other health care providers for lost revenue and other costs associated with COVID-19. The measure also calls for spending up to $16 billion to replenish the nation's depleted stockpile of medical gear, such as ventilators, medicines and personal protective equipment, or PPE.

But health care businesses will get billions of dollars in additional funding not directly related to the pandemic, in some cases because Congress agreed to reverse scheduled cuts in the rates paid by Medicaid and Medicare, which the federal government had tried for years to impose.

"Anything that could tangentially be related to the crisis lobbyists tried to get stuffed in this bill ― particularly health-care-related items," said Steve Ellis, vice president of Taxpayers for Common Sense, a nonpartisan watchdog group. While the stimulus package is "not as big" a "Christmas tree" as some other bills, Ellis said, "I'm sure we'll find a few baubles and gifts along the way."

Hospitals have won widespread praise as their doctors and other medical staffs labor under perilous conditions, including shortages of protective gear. And, perhaps not surprisingly, the industry emerged as a big winner in the stimulus negotiations. Not only can hospitals draw on the $100 billion fund to stem their losses and cover other costs, but they will also see a boost in one stream of revenue as Congress overturned some planned rate cuts.

More than 3,000 hospitals that treat outsize numbers of Medicaid or uninsured patients, for instance, will share in an $8 billion windfall through the stimulus provision that reverses cuts in their Medicaid payments for 2020 and 2021.

Separately, hospitals will rake in at least $3 billion more because of a temporary suspension of a 2% cut in Medicare fees, according to the Federation of American Hospitals, which represents more than 1,000 for-profit hospitals and health systems. The infusion of cash also benefits doctors, nursing homes, home health companies and others.

"That's welcome news during this time of crisis," said Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare.

Also tucked into the stimulus: a rollback of planned rate cuts to clinical laboratories and some medical equipment suppliers.

At this stage, it is unclear how much these measures will add to the COVID-19 tab ― or if far more stimulus would be required for the health care industry to rebound.

Take the 2% rate cut known as "the sequester." The Office of Management and Budget expected it would save Medicare $16.2 billion in fiscal 2021. But the stimulus bill rescinds that rate cut from May 1 through the end of this year. As part of the legislation, Congress said it would, in effect, recoup the payments later by adding another year to the sequester. Whether lawmakers will follow through on that is anyone's guess.

Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association (MGMA), expects the sequester relief to translate to a "huge" financial boost for more than 15,000 medical practices his group represents.

"This would never have been done under any other circumstances," Gilberg said. "The situation was recognized as dire."

Dr. Patrice Harris, president of the American Medical Association, said the stimulus offers "needed financial relief to hard-hit workers, health systems and physician practices. At this critical moment, physician practices need significant financial support to sustain themselves and continue to meet the health care needs of all Americans during this time."

Similarly, American Hospital Association CEO Rick Pollack called the legislation "an important first step forward. But, he added, "more will need to be done to deal with the unprecedented challenge of this virus."

In a nod to clinical laboratories, which have helped bail out the federal government's early failure to supply enough COVID-19 tests, the stimulus delayed planned rate cuts in 2021 likely to amount to tens of millions of dollars in revenue. Medicare officials have been at odds with the lab industry for years over rates for lab tests.

While other health care interests praised the bill, the laboratory trade association said it comes up short.

Just before the Senate passed the stimulus bill Wednesday, American Clinical Laboratory Association President Julie Khani slammed Congress for not designating funding to support labs. She said labs were in "an untenable situation, absorbing growing, uncompensated costs for testing specimens with no assurance that they will be appropriately or fairly reimbursed for all the tests they are performing."

She added a not-so-veiled threat, saying: "If Congress fails to designate essential emergency funding for clinical laboratories to support our efforts, labs will be soon be forced to make difficult decisions about whether they can keep building the [testing] capacity our nation needs."

The lab association, in a statement to Kaiser Health News, said labs have absorbed "stunning" Medicare reimbursement cuts of as much as 30% for many common tests in recent years.

In public securities filings this year, lab giants Quest Diagnostics Inc. and Laboratory Corp of America Holdings, known as LabCorp, reported they expected rate cuts in 2020 totaling more than $150 million. LabCorp said it supported the views of the lab association. Quest did not respond to a request for comment.

While labs processing COVID-19 tests missed out on direct funding, they could be eligible for some of the $100 billion allocated for hospitals and other providers to cover their losses, congressional aides said.

And the stimulus measure states that even in the event a lab is out-of-network, health plans are expected to pay the price it sets — as long as the lab publishes that price online — or negotiate with the lab.

Given that laws in some states ban surprise billing in particular, this provision seems to favor the labs, said Katie Keith, a Georgetown University law professor and health policy expert. "No one just lets the provider set the price," she said.

The lab association disputes that, saying that many health plans are expected to pay them less than the $51.50 government recommended for a COVID-19 test.

Just how the $100 billion in health care funding will be distributed and how much oversight will occur is another unknown.

Health and Human Services Secretary Alex Azar has the authority to decide how long the emergency provisions remain in effect. Tracking all that money will be a challenge as well.

Ellis, the taxpayer advocate, noted that no government agency "is ready to handle the rush of extra funding." He said that the stimulus grants extra resources to inspector general offices to monitor spending.

"There will be waste, there will be abuse," he said. "It's about exposing and rooting it out."

The HHS Office of Inspector General expects to receive $4 million to support this oversight, according to spokesman Donald White.

Some groups aren't waiting to compete over the $100 billion. The MGMA sent a letter March 27 to Azar and the Centers for Medicare & Medicaid Services chief Seema Verma asking for more direct help. Gilberg noted that some medical practices, such as doctors who perform colonoscopies, have not been able to continue their work.

"Doctors and physician practices are having a lot of trouble right now," Gilberg said. "They are literally shut down, and they are having financial troubles. Their operations have come to a full halt."

KHN correspondents Rachana Pradhan and Emmarie Huetteman contributed to this report.

Fred Schulte: fschulte@kff.org, @fredschulte

Coronavirus Patients Caught In Conflict Between Hospital And Nursing Homes

KFF Health News, March 30, 2020

Hospitals need to clear out patients who no longer need acute care. Nursing homes don't want to take discharged patients for fear they'll bring the coronavirus with them.

This article was first published on Monday, March 30, 2020 in Kaiser Health News.

By Judith Graham

A wrenching conflict is emerging as the COVID-19 virus storms through U.S. communities: Some patients are falling into a no man's land between hospitals and nursing homes.

Hospitals need to clear out patients who no longer need acute care. But nursing homes don't want to take patients discharged from hospitals for fear they'll bring the coronavirus with them.

"It's a huge and very difficult issue," said Cassie Sauer, president of the Washington State Hospital Association, whose members were hit early by the coronavirus.

Each side has legitimate concerns. Hospitals in coronavirus hot spots need to free up beds for the next wave of critically ill patients. They are canceling elective and nonessential procedures. They are also trying to move coronavirus patients out of the hospital as quickly as possible.

The goal is to "allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities," Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said a few weeks ago as the federal agency relaxed rules restricting which Medicare patients can receive nursing home care.

Nursing homes are alarmed at the prospect of taking patients who may have coronavirus infections. The consequences could be dire. The first nursing home known to have COVID-19, the Life Care Center in Kirkland, Washington, saw the virus spread like wildfire. It killed 37 people.

"We're looking at case fatality rates of 30, 40, 50% in nursing homes when coronavirus gets introduced," said Christopher Laxton, executive director of AMDA — the Society for Post-Acute and Long-Term Care Medicine, which represents nursing home medical directors.

Fears extend to patients with other conditions, such as strokes or heart attacks, who've been in the hospital and do not have COVID-19 symptoms but could harbor the virus.

In its most recent guidance, the American Health Care Association, an industry trade group, said nursing homes can accept patients "who are COVID negative or do not have symptoms." If someone has symptoms such as a dry cough or fever, they "should be tested for COVID-19 before being admitted to the facility." If someone is COVID positive, they should be kept only "with other COVID positive residents."

But nursing home doctors worry this doesn't go far enough. According to a resolution by the California Association of Long Term Care Medicine, nursing homes should not have to take patients known to have the coronavirus unless "they have two negative tests that are 24 hours apart, OR 10 days after admission AND no fever for 72 hours." A new AMDA resolution echoes this caution.

"We have an obligation to our patients to draw the line," said Dr. Michael Wasserman, president of the California association. "Increasing the number of COVID-19 positive residents in facilities — whether these facilities have patients with the virus or not — raises the risk of infecting the uninfected and dramatically increasing the number of deaths."

For their part, hospital leaders say an emphasis on testing before discharging patients is impractical, given the shortage of tests and delays in receiving results.

"Many nursing homes are requiring a negative COVID-19 test even for patients who were in the hospital for nothing to do with COVID," said Sauer in Washington state. "We don't agree with this. It's using up very limited testing resources."

Nowhere are tensions higher than in New York, where Gov. Andrew Cuomo has said 73,000 extra hospital beds will be needed within weeks to treat a surge of COVID-19 patients. Hospitals in the state have 53,000 beds.

On Wednesday, the New York State Department of Health issued an advisory noting: "No resident shall be denied re-admission or admission to the NH [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19."

Speaking on behalf of nursing home physicians, AMDA voiced strong opposition, calling the policy "over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles" in a statement.

Some nursing homes are sending residents with suspected coronavirus to hospitals for evaluation and then refusing to take them back until tests confirm their negative status.

"Essentially, they're dumping patients on hospitals and saying, 'Too bad — you're stuck with them now,'" said a consultant who works closely with hospitals and spoke on the condition of anonymity.

Others want to do their part to serve COVID-19 patients. "It is our obligation to keep the health care system flowing," said Scott LaRue, president of ArchCare, the health care system of the Archdiocese of New York.

LaRue has no illusions about keeping the coronavirus out of ArchCare's five nursing homes, which, combined, have 1,700 beds.

"In New York City the virus is everywhere," he said. That means it has to be managed, not avoided. "Our intention is to take COVID-19 stable patients" and move them to a single floor at each nursing home, he said.

That will happen under two conditions, LaRue said. First, ArchCare will need sufficient personal protective equipment — gowns, masks and face shields — for its staff. Currently, the system can't get face shields. It was due to run out of gowns by Wednesday.

Second, ArchCare will need to test whether its protocols for managing COVID-positive patients are working. Those include putting patients in isolation, monitoring them more closely, limiting the number of people who can go in, and ensuring that staff use personal protective equipment and are trained properly.

So far, only one of its nursing home patients is known to have COVID-19.

"We won't know for 14 days if the steps we're taking are working," LaRue said.

But it's unrealistic to expect other nursing homes to follow suit.

"I would be surprised if 10% to 15% of skilled nursing facilities in the U.S. could take a COVID-positive patient and treat that patient safely while ensuring that other residents in the home are safe," said David Grabowski, a professor of Health Care Policy at Harvard Medical School.

In a new commentary in the Journal of the American Medical Association, Grabowski calls for establishing "centers of excellence" to care for patients recovering from COVID-19 and building "temporary capacity" in hot spots where the need for post-hospital services is likely to surge.

That's beginning to happen. On Tuesday, Cuomo announced that a field hospital being built by the U.S. Army Corps of Engineers to house overflow coronavirus patients at the Jacob K. Javits Convention Center in New York City would include 1,000 beds for patients who don't need acute care services.

On Wednesday, a unit of Partners HealthCare, a large Massachusetts health care system, announced a new center for patients recovering from COVID-19 on the fourth floor of Spaulding Hospital for Continuing Care, a long-term care hospital in Cambridge. The center, set to open soon, will have 60 beds and accept patients from Massachusetts General Hospital and Brigham and Women's Hospital.

In the Twin Cities area of Minnesota, Allina Health, which operates 11 hospitals, is partnering with Presbyterian Homes & Services to convert a 50-bed skilled nursing home to a "step-down site," said Dr. Emily Downing, a vice president of Allina Health. The goal is to help COVID-19 patients recover so they can return to nursing homes or senior living communities.

Katie Smith Sloan, president of LeadingAge, which represents not-for-profit nursing homes, home care agencies and assisted living centers, said she was hearing about nascent plans to reopen closed nursing homes for COVID-19 patients. Government agencies need to make financing available to build extra capacity to care for these patients, she said.

As for patients who need less intensive care or who need to be quarantined after the hospital to ensure they aren't infectious, other options exist.

"King County has bought a hotel and is leasing another and is looking at what are now empty ambulatory surgery centers or a Christian summer camp in the area," said Sauer of the Washington State Hospital Association.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

Physicians Fear For Their Families As They Battle Coronavirus With Too Little Armor

KFF Health News, March 28, 2020

Dr. Jessica Kiss has had just one N95 respirator mask since March 16, when she got a box of five for her practice from a physician friend.

By Laura Ungar

This article was first published on Friday, March 27, 2020 in Kaiser Health News.

Dr. Jessica Kiss’ twin girls cry most mornings when she goes to work. They’re 9, old enough to know she could catch the coronavirus from her patients and get so sick she could die.

Kiss shares that fear, and worries at least as much about bringing the virus home to her family — especially since she depends on a mask more than a week old to protect her.

“I have four small children. I’m always thinking of them,” said the 37-year-old California family physician, who has one daughter with asthma. “But there really is no choice. I took an oath as a doctor to do the right thing.”

Kiss’ concerns are mirrored by dozens of physician parents from around the nation in an impassioned letter to Congress begging that the remainder of the relevant personal protective equipment be released from the Strategic National Stockpile, a federal cache of medical supplies, for those on the front lines. They join a growing chorus of American health care workers who say they’re battling the virus with far too little armor as shortages force them to reuse personal protective equipment, known as PPE, or rely on homemade substitutes. Sometimes they must even go without protection altogether.

“We are physically bringing home bacteria and viruses,” said Dr. Hala Sabry, an emergency medicine physician outside Los Angeles who founded the Physician Moms Group on Facebook, which has more than 70,000 members. “We need PPE, and we need it now. We actually needed it yesterday.”

The danger is clear. A March 21 editorial in The Lancet said 3,300 health care workers were infected with the COVID-19 virus in China as of early March. At least 22 died by the end of February.

The virus has also stricken health care workers in the United States. On March 14, the American College of Emergency Physicians announced that two members — one in Washington state and another in New Jersey — were in critical condition with COVID-19.

At the private practice outside Los Angeles where Kiss works, three patients have had confirmed cases of COVID-19 since the pandemic began. Tests are pending on 10 others, she said, and they suspect at least 50 more potential cases based on symptoms.

Ideally, Kiss said, she’d use a fresh, tight-fitting N95 respirator mask each time she examined a patient. But she has had just one mask since March 16, when she got a box of five for her practice from a physician friend. Someone left a box of them on the friend’s porch, she said.

When she encounters a patient with symptoms resembling COVID-19, Kiss said, she wears a face shield over her mask, wiping it down with medical-grade wipes between treating patients.

As soon as she gets home from work, she said, she jumps straight into the shower and then launders her scrubs. She knows it could be devastating if she infects her family, even though children generally experience milder symptoms than adults. According to the Centers for Disease Control and Prevention, her daughter’s asthma may put the girl at greater risk of a severe form of the disease.

Dr. Niran Al-Agba of Bremerton, Washington, said she worries “every single day” about bringing the COVID-19 virus home to her family.

“I’ve been hugging them a lot,” the 45-year-old pediatrician said in a phone interview, as she cuddled one of her four children on her lap. “It’s the hardest part of what we’re doing. I could lose my husband. I could lose myself. I could lose my children.”

Al-Agba said she first realized she’d need N95 masks and gowns after hearing about a COVID-19 death about 30 miles away in Kirkland last month. She asked her distributor to order them, but they were sold out. In early March, she found one N95 mask among painting gear in a storage facility. She figured she could reuse the mask if she sprayed it down with a little isopropyl alcohol and also protected herself with gloves, goggles and a jacket instead of a gown. So that’s what she did, visiting symptomatic patients in their cars to reduce the risk of spreading the virus in her office and the need for more protective equipment for other staffers.

Recently, she began getting donations of such equipment. Someone left two boxes of N95s on her doorstep. Three retired dentists dropped off supplies. Patients brought her dozens of homemade masks. Al-Agba plans to make these supplies last, so she’s continuing to examine patients in cars.

In the March 19 letter to Congress, about 50 other physicians described similar experiences and fears for their families, with their names excluded to protect them from possible retaliation from employers. Several described having few or no masks or gowns. Two said their health centers stopped testing for COVID-19 because there is not enough protective gear to keep workers safe. One described buying N95 masks from the Home Depot to distribute to colleagues; another spoke of buying safety glasses from a local construction site.

“Healthcare workers around the country continue to risk exposure — some requiring quarantine and others falling ill,” said the letter. “With emergency rooms and hospitals running at and even over capacity, and as the crisis expands, so does the risk to our healthcare workers. And with a shortage of PPE, that risk is even greater.”

Besides asking the government to release the entire stockpile of masks and other protective equipment — some of which has already been sent to states — the doctors requested it be replenished with newly manufactured equipment that is steered to health care workers before retail stores.

They called on the U.S. Government Accountability Office to investigate the distribution of stockpile supplies and recommended ways to ensure they are distributed as efficiently as possible. They said the current system, which requires requests from local, state and territorial authorities, “may create delays that could cause significant harm to the health and welfare of the general public.”

At this point, Sabry said, the federal government should not be keeping any part of the stockpile for a rainy day.

“It’s pouring in the United States right now,” she said. “What are they waiting for? How bad does it have to get?”

Laura Ungar: lungar@kff.org, @laura_ungar

Hospital Suppliers Take To The Skies To Combat Dire Shortages Of COVID-19 Gear

KFF Health News, March 26, 2020

As the coronavirus sweeps the nation, a new survey reveals widespread medical shortages while hospitals give up on a fractured supply chain and take matters into their own hands with planes sprinting past cargo ships.

By Christina Jewett and Lauren Weber

This article was first published on Thursday, March 26, 2020 in Kaiser Health News.

Hospitals in the New York City area are turning to a private distributor to airlift millions of protective masks out of China. The U.S. military is flying specialized swabs out of Italy. And a Chicago-area medical supply firm is taking to the skies as well — because a weekslong boat trip across the ocean just won't do.

The race to import medical supplies reflects a nationwide panic over a dwindling supply of the masks, gowns and other protective gear that health care workers need amid the growing coronavirus pandemic. Demand is outstripping what's available due to a damaged supply chain heavily reliant on China and a struggling Strategic National Stockpile. U.S. manufacturing giants like 3M have not yet made up the difference.

A sweeping national survey out Wednesday drives home that nearly a quarter of hospitals have fewer than 100 N95 masks on hand and 20% report an immediate need for ventilators. In the hardest-hit areas, like New York City, the shortages are potentially life-threatening to patients as well as health care workers.

About 260 health systems representing 990 major hospitals responded to the March 16-20 survey by Premier Inc., a group purchasing organization that negotiates with suppliers for discounts. While the survey provides a fresh picture of nationwide hospital operations, the number of U.S. COVID-19 cases has soared tenfold since the survey began ― from fewer than 5,000 to more than 55,000 as of Wednesday afternoon.

"Absent additional interventions from the government or private sector, we don't foresee the current status quo changing," said Soumi Saha, senior director of advocacy for Premier. "And the current status quo is not acceptable."

Saha said the national stockpile "is intended to be a band-aid, not a long-term solution." Premier called on the Trump administration to either further implement the Defense Production Act to ramp up domestic manufacturing or provide more clear direction on which medical supplies are needed and streamline distribution. FEMA announced Tuesday it did not use the Defense Production Act for test kits after previously stating it would.

The alarm bells ringing from the hospital community come in contrast to a more subdued message from FEMA, which is helping hospitals procure needed goods.

"The private sector can directly purchase [personal protective equipment] from manufacturers and distributors, as they normally do," FEMA press secretary Lizzie Litzow said in a statement. "The private sector can also accept donations from other private sector entities." The statement pointed to a "how to help" document that outlines how individuals and companies can share supplies or other resources.

In recent days, volunteer efforts have ramped up to help health providers who've taken to Twitter and other social media with pleas for more protective gear. Grassroots efforts have sprung up, with veterinary, computer, construction and industrial businesses donating goods while sewing circles churn out cloth masks.

During a White House press briefing Tuesday, President Donald Trump said FEMA is distributing more than 8 million N95 respirators, 14 million surgical masks and 2.4 million face shields.

"The federal government is using every resource at its disposal to acquire and distribute critical medical supplies," the president said.

3M, a major American manufacturer of the N95 masks, said on March 20 it had doubled its global output of the crucial N95 respirators and plans to further increase output. Currently, over 30 million industrial and health care specific N95s are being produced for U.S. health care use by the company each month. Shipments totaling half a million 3M masks were scheduled to start arriving in New York and Seattle on Monday from its South Dakota plant.

The influx of goods comes as health care providers are now using four to 10 times more protective gear once a COVID-19 patient enters their doors than they typically use. This has forced hospitals already dealing with cases to scramble even more than health care facilities yet to get any cases, though shortages are crippling all areas of the health care industry.

"It's a total change in what we are used to as a society around availability," said Cathy Denning, senior vice president of sourcing operations for Vizient, an analytics and advisory firm that also does health care group purchasing. "From our perspective, it's this unbelievable place we find ourselves in — realizing we have a vulnerable supply chain."

As the coronavirus crippled China, the center of commerce for low-margin products like face masks and sanitizing wipes, the U.S. supply chain began to fall apart. With global competition for the same safety gear, the crisis deepened, and big national suppliers aren't coming up with enough products to meet the crushing demand.

And waiting about a month for a cargo ship of supplies to arrive from China is a luxury of time that hospitals cannot afford ― even though ships can carry over 10 times more supplies than a cargo plane could.

Medline, a Chicago-area medical supplier, started delivering face masks by airplane last week after manufacturing resumed in China. According to spokesperson Stacy Rubenstein, flying the supplies in will shorten the "manufacturing-to-dock" time by three to four weeks, and the firm will not be passing along the "significant increase in cost" to customers.

But the demand is still 300% higher than traditional inventory levels, Rubenstein said in an email.

Elsewhere, hospitals are reaching out to Michael Einhorn, president of Dealmed, the medical products distributor and supplier working with 12 New York metro area hospitals — desperate for products he cannot always secure.

"Does it cost the hospitals a lot of money? No question about it. But right now, that's what they need to do to secure product," Einhorn said. "We can't wait for it to come overseas."

He's paying up to $40,000 for shipments arriving on multiple planes from Shanghai to New York's John F. Kennedy International Airport and Los Angeles International Airport — and sometimes losing money due to the high shipping costs.

The other backstop for hospitals was the national stockpile, which has come up far short.

Despite receiving 49,200 N95 masks, 115,000 surgical masks, 21,420 surgical gowns, 21,800 face shields and 84 coveralls from the national stockpile, the Colorado Department of Public Health and Environment estimated in a press release Monday that those supplies would last approximately one full day of statewide operations.

Einhorn said that hospitals are panicking, having lost faith in the supply chain as they cannot find products they so desperately need.

"The strategic national stockpile, with all due respect, was a failure," he said.

The hospitals reported in the survey that their supply of N95 masks are their chief concern, with the best-supplied hospitals having about a 10-day supply on hand.

Hospitals identified hand sanitizer as the second-most pressing shortage, with 64% of respondents saying they were already running out. Next was surgical masks, which provide less protection than the N95 masks. Nearly half of hospitals had fewer than 1,000 on hand; a quarter of them reported going through 1,000 per day.

To keep up with that kind of demand, Einhorn said, more needs to be done to secure the products from China.

"One of the things we have been asking for is assistance getting these products quickly from China to here," said Einhorn. "Instead, we're doing drives of people dropping off three boxes of face masks."

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Seattle Nurses Scrounge For Masks To Stay Safe On Pandemic's Front Lines

KFF Health News, March 23, 2020

At some hospitals, nurses and doctors said they are being told that they should try to clean and reuse their N95 masks.

This article was first published on Monday, March 23, 2020 in Kaiser Health News.

By Will Stone

As the caseload of patients with the new coronavirus grows, masks and other personal protective equipment are in short supply — and nurses in Washington state are resorting to workarounds to try to stay safe.

Wendy Shaw, a charge nurse for an emergency room in Seattle, said her hospital and others have locked up critical equipment like masks and respirators to ensure they don't run out.

Shaw is the de facto gatekeeper, and is now required to run through a list of questions when anyone comes to get a mask: "What are you using it for? What patient? What's the procedure?"

"I have become a 'jailer' in a sense of these masks," she said.

"We now have to learn how to work with less, and how to be good stewards of the resources that we have," Shaw said.

For Shaw, there's a very personal stress driving her to be careful. She has Type 1 diabetes, and so does her young son, which puts her at high risk for complications if she were to be infected.

"I am cleaning like I have never cleaned before. I am hyperaware of what I touch, who has brushed up against me," said Shaw. "We think about this all the time. Every day I wake up without a fever or a cough is a win for me."

At some hospitals, nurses and doctors said they are being told that, contrary to standard protocol of disposal after a single use, they should try to clean and reuse their N95 masks, a respirator that protects the face from airborne particles and contaminated liquid.

Meanwhile, office staff at the corporate headquarters of Providence St. Joseph Health in Renton, Washington, have opened an ad hoc workshop where they are assembling masks and face shields on their own, to bolster resources.

"At any given time, we are days away from running out of personal protective equipment," said Melissa Tizon, with Providence St. Joseph Health.

Tizon said the health system has already delivered 500 face shields to Providence-affiliated hospitals in Seattle and Everett, Washington, and plans to start sewing masks in the coming days.

Some nurses are even crowdsourcing masks.

Bobbie Habdas, an ICU nurse at Swedish Medical Center, took to Facebook asking for help from her community.

"I never thought that we'd necessarily be doing this," said Habdas.

Her post gained lots of attention, and she collected more than a hundred masks to share with co-workers.

"Honestly, it shocked me and it really touched me — it's extremely appreciated," she said.

The outpouring was a bright spot, but Habdas wonders why nurses have to scrounge for supplies, in addition to their regular duties.

"There is a huge feeling of panic, not only externally, but also internally within the hospital," said Habdas.

She said spending time looking for supplies during her shift doesn't help with the stress of responding to the coronavirus pandemic. Patients have died from the disease in Washington, with at least 74 COVID-19 deaths recorded across the state as of Thursday afternoon.

Sally Watkins, executive director of the Washington State Nurses Association, said nurses are being forced to make do with less.

"They are not being protected at the level that they should be," said Watkins. She hopes the region will get more supplies from the federal stockpile soon.

Communication Breakdowns

After 39 years as an intensive care nurse, Mary Mills has dealt with other infectious disease crises, but her hospital's response to the coronavirus outbreak feels different. She remembers helping to intubate HIV patients in the early days of the AIDS crisis, when there was still a lot of fear and unknowns about that illness.

"Everybody was on the same page," Mills said. "There was clear communication."

Mills works at one of the five hospitals run by Swedish Medical Center in the Seattle area. "I hate to say I don't feel particularly supported now," she said.

Like many health care workers, Mills feels frustrated because the guidance on when to use personal protective equipment, or PPE, keeps shifting, sometimes daily.

"What they decide I need, in terms of my safety, is being changed based on availability of product, rather than the science," Mills said.

"This is super contagious. We can spread it to our kids, our parents and grandparents," she added.

Worries About Health Care Worker Exposure

Mills believes that hospital managers have not been taking nurses' concerns seriously enough, especially when it came to testing patients and staff in the early days of the outbreak.

She said two nurses she works with have already become sick with what seemed to be COVID-19.

"One went out with a cough and a fever, all the classic five symptoms," Mills said. "On the eighth day, they finally agreed to have her tested for COVID-19."

Mills said this type of response only erodes nurses' trust in hospital leadership, harming a relationship that is critical as the entire Seattle-area health care workforce is called upon to care for an increasing number of patients with the disease.

Health care workers being exposed to coronavirus is a central concern throughout the region. Multiple hospitals in the Seattle area have reported cases among staff at their facilities. An emergency room doctor in Kirkland was hospitalized after being infected.

Dr. Chris Dale, the chief quality officer for Swedish, said his hospital system is focused on caregiver safety.

"We cannot effectively provide safe care for patients if our caregivers first aren't safe," said Dale.

The hospital just launched pop-up clinics where staff and patients can get tested. He said that testing around Washington has improved significantly as more labs have come online in recent days. Currently, results are coming back within three to four days, he said, compared with earlier, when it took a week.

He said the number of Swedish Medical Center health care workers who have contracted COVID-19 remains "low," but did not give specific numbers.

"With this extraordinary pandemic, and the squeeze that we are seeing on supplies, we need to balance both supply and the very real need to keep caregivers safe," said Dale.

Swedish follows the World Health Organization guidance when treating patients with suspected or confirmed cases of COVID-19, he said.

Staffing Issues

Nurses from Swedish Medical Center began confronting this pandemic at a time when they were already locked in a divisive labor dispute, related to staffing levels. In January, thousands of health care workers from their union went on a three-day strike, unrelated to the coronavirus crisis. The nurses contend that chronic understaffing inside the hospitals can negatively affect patient safety.

Dale said Swedish has recently hired about 300 temporary nurses, called travel nurses, and is actively recruiting more. But Mills still worries there won't be enough nurses to handle the surge in patients.

"It is not just about physical beds or ventilators," said Mills. "A room and a ventilator don't mean anything if you don't have a nurse."

Mills said she hopes management starts dealing with these urgent issues. After decades of working in the ICU, she said her No. 1 commitment is to her patients. Already, she has treated some patients with COVID-19 who died in isolation — sometimes with no family members there in-person.

The hospital's policy currently does not allow any visitors to COVID-19 patients for safety reasons, though the hospital said it makes exceptions "in extreme circumstances."

"The tragedy of not having family there to support the super sick … you feel a greater burden to deliver some form of compassion to these people who are totally isolated," said Mills. "The only people there are the ICU nurses."

This story is part of a partnership that includes NPR and Kaiser Health News.

Will Stone: @WStonereports

CDC Coronavirus Testing Decision Likely To Haunt Nation For Months To Come

KFF Health News, March 23, 2020

Public health officials are just beginning to grapple with the fallout from that early bungling of testing, which is likely to haunt the country in the months to come.

This article was first published on Monday, March 23, 2020 in Kaiser Health News.

By Rachana Pradhan

As the novel coronavirus snaked its way across the globe, the Centers for Disease Control and Prevention in early February distributed 200 test kits it had produced to more than 100 public health labs run by states and counties nationwide.

Each kit contained material to test a mere 300 to 400 patients. And labs, whether serving the population of New York City or tiny towns in rural America, apparently received the same kits.

The kits were distributed roughly equally to locales in all 50 states. That decision presaged weeks of chaos, in which the availability of COVID-19 tests seemed oddly out of sync with where testing was needed.

A woman in South Dakota with mild symptoms and no fever readily got the test and the results. Meanwhile, politicians in places like New York, Boston, Seattle and the San Francisco Bay Area — all in the throes of serious outbreaks ― couldn't get enough tests to screen ill patients or, thereby, the information they needed to protect the general public and stem the outbreak of the virus, whose symptoms mimic those of common respiratory illnesses.

Rapid testing is crucial in the early stages of an outbreak. It allows health workers and families to identify and focus on treating those infected and isolate them.

Yet health officials in New York City and such states as New York, Washington, Pennsylvania and Georgia confirmed to Kaiser Health News that they each initially got one test kit, calling into question whether they would have even stood a chance to contain the outbreaks that would emerge. They would soon discover that the tests they did receive were flawed, lacking critical components and delivering faulty results.

During those early weeks, the virus took off, infecting thousands of people and leading to nationwide social distancing and sheltering in place. Public health officials are just beginning to grapple with the fallout from that early bungling of testing, which is likely to haunt the country in the months to come.

Too Little Too Late

The first shipment to Washington state arrived more than two weeks after officials there announced the first U.S. case of coronavirus, and at a moment when deadly outbreaks of the disease were already festering in places like the Life Care Center in Kirkland. Within weeks, three dozen people infected with COVID-19 would die at the nursing home in the suburbs of Seattle.

The spread of COVID19 would not take long to overwhelm the state, which as of Friday had more than 1,300 cases.

The Trump administration in recent days has attempted to speed testing for the virus after early missteps hampered the government's response to contain the contagion, and officials have had to respond to a barrage of criticism from public health experts, state officials and members of Congress.

Federal health officials have eased the process for university and commercial labs to perform their own tests, and they are ramping up their capacity. As of March 16, public and private labs in the U.S. had the ability to test more than 36,000 people a day, according to estimates compiled by the American Enterprise Institute, a conservative-leaning think tank in Washington, D.C., a figure expected to rapidly escalate in coming weeks. That figure, however, can vary considerably by state and does not indicate how many tests are actually given to patients.

"We are now beginning to see that they have spread out in a prioritized way. We asked them to prioritize the regions that were mostly affected," Deborah Birx, the coronavirus response coordinator for the White House Coronavirus Task Force, said Wednesday of private labs' testing, without elaboration.

The scaling up of testing is set to take place after weeks of faltering and hundreds, if not thousands, of undiagnosed people spreading the virus. For example, New York's state health department received a faulty CDC test kit on Feb. 8 for 800 patient specimens, an amount that's consistent with other states, according to a spokesperson. It later began testing patients with a test that state officials developed based on the CDC protocol and has significantly increased testing — as of Friday, more than 7,200 people had tested positive statewide.

In New York City, the first batch was obtained on Feb. 7.

"The other state and local public health laboratories got test kits as they became available," said Eric Blank, chief program officer of the Association of Public Health Laboratories.

Places in the middle of the country with no outbreaks had the luxury of time to plan. For example, Missouri officials have had about 800 tests to work with, leading to only 395 performed so far in the region by public health labs ― 26 of which were positive. When private lab tests are accounted for, as of Friday there were 47 confirmed cases.

Health care providers and public health staff in the state, however, benefited from the fact that there is less international travel to the region, according to infectious disease expert Dr. Steven Lawrence of Washington University in St. Louis.

"This is very similar to 1918 with the influenza pandemic — St. Louis had more time to prepare and was able to put measures in place to flatten the curve than, say, Philadelphia," Lawrence said. "Seattle didn't have an opportunity to prepare as much in advance."

While commercial labs are coming online, strict restrictions are limiting testing capabilities, Lawrence said.

"The state has had their hands tied," he added.

Waiting And Wondering

Because of a widespread lag in testing, it is still a mystery for thousands of people to know whether they've come into contact with an infected person until well after it happens. As of Friday, the pandemic had killed more than 11,000 globally. More than 16,000 Americans were confirmed infected and at least 216 have died.

"CDC will distribute tests based on where they can do the most good. But without hospital-based testing and commercial testing, it will not be possible to meet the need," said Tom Frieden, who led the CDC during the Obama administration and is a former commissioner of the New York City Health Department.

In California, public school teacher Claire Dugan, whose state was among the hardest hit in the initial wave of U.S. coronavirus cases, was told she didn't qualify for testing because she had not traveled abroad to any country with an outbreak of the virus or been in contact with an infected person. Dugan, who lives in the San Francisco Bay Area and is already medically fragile after a stray bullet nearly killed her while driving four years ago, sought a test from her doctor after registering a temperature of 100.7 degrees earlier this month.

"There are a lot of layers as to why this is so messed up," said Dugan, who relies on a feeding tube and said she sought a test not only to protect herself but her students. "It's community spreading right now, so it's kind of silly we're still insisting on [the early criteria for testing]. How would I know?"

Since the CDC's initial distribution, states have been reordering more tests through the office's International Reagent Resource ― a long-standing tool that public health labs have relied on. They have also revised testing protocols to use only one sample per person, which boosts the number of people screened.

Yet problems still abound with tests or other materials needed to be able to detect the virus. California Gov. Gavin Newsom said on March 12 that county public health labs can't use all of the 8,000 test kits the state has because they are missing key components.

In Pennsylvania, state officials weren't able to begin testing until March 2 because of problems with the CDC's initial kit, according to Nate Wardle, a spokesperson at its department of health. New York City received two newly manufactured CDC test kits on Feb. 29 and also began performing tests March 2, its health department told KHN.

"We are still limited on extraction kits," Mandy Cohen, the Health and Human Services secretary in North Carolina, said in an interview in mid-March. Officials earlier this month could test only 300 patients because of shortages in the extraction materials needed to register whether the novel coronavirus is present.

In North Dakota, Loralyn Hegland wrote her physician's practice an email on March 10 with the subject line "dry cough," wondering if she should come in for testing after learning that was one symptom of COVID-19. The recommendation she got echoes those of countless others across the U.S., saying her risk of being exposed was very low because she hadn't traveled outside the U.S. and had not come into contact with a person who had been "definitely" diagnosed with the virus.

Hegland, who lives in Fargo, didn't have a fever but decided to shelter herself, anyway, out of caution.

Would she push to get a test?

"What's the point?" she said. "You can't know what you don't know. It's just that simple. How else do you explain it to people when you're not testing?"

KHN Midwest correspondent Lauren Weber in St. Louis contributed to this article.

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

Coronavirus Threatens The Lives Of Rural Hospitals Already Stretched To Breaking Point

KFF Health News, March 22, 2020

The AHA is asking Congress for $100 billion for all hospitals to offset coronavirus costs, citing rural hospitals' inability to withstand huge losses for long.

This article was first published on Saturday, March 21, 2020 in Kaiser Health News.

By Lauren Weber

Rural hospitals may not be able to keep their doors open as the coronavirus pandemic saps their cash, their CEOs warn, just as communities most need them.

As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace — profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that's in short supply. Vice President Mike Pence called on hospitals nationwide Wednesday to delay elective surgeries to free up capacity and resources for future coronavirus patients.

The American Hospital Association responded Thursday by asking Congress for $100 billion for all hospitals to offset coronavirus costs, citing rural hospitals' inability to withstand huge losses for long.

"If we're not able to address the short-term cash needs of rural hospitals, we're going to see hundreds of rural hospitals close before this crisis ends," warned Alan Morgan, the head of the National Rural Health Association, which represents 21,000 health care providers and hospitals. "This is not hyperbole."

Well before the COVID-19 threat, rural health care's profitability had collapsed nationwide due to a combination of narrowing Medicare reimbursements, a larger share of patients lacking high-paying private insurance and the hollowing out of rural America. Given such pressures, more than 120 rural hospitals have been forced to close over the past decade.

Those hospitals in small-town America that have survived rely heavily on moneymakers such as elective surgeries, physical therapy and lab tests to make their razor-thin margins work. But, according to the Chicago-based Chartis Center for Rural Health, almost half of them still operate in the red.

So the added financial hit from the coronavirus outbreak could be the final straw for many rural hospitals — exposing the complicated business dynamics at play within the United States' critical public health infrastructure.

"This virus, and what it is causing for these hospitals, is the perfect storm that will close these hospitals at a time this country critically needs them," said Robin Rau, CEO of Miller County Hospital in southwestern Georgia. "This is going to be the death blow to them."

Two weeks ago, she started eliminating all medical services that were not urgent. She estimated that has cut off at least half of the hospital's revenue. Other CEOs warned similar cuts at their hospitals mean they won't make payroll in the coming weeks.

The National Rural Health Association, along with many rural hospital executives, is lobbying for immediate cash assistance, no-interest loans, Medicare reimbursement adjustments and other suggestions to alleviate the pain. The association favors a bailout plan being from Sens. John Barrasso (R-Wyo.) and Michael Bennet (D-Colo.), which in initial drafts called for the equivalent of a three-month advance based on hospitals' previous patient numbers, according to Bennet's office.

"Rural hospitals have already been closing their doors at startling rates, and this crisis will only exacerbate that fact," Bennet said in a statement to KHN. "There is an incredible opportunity for rural hospitals to shoulder some of the burdens of caring for patients and helping to meet possible bed shortages."

Still, many rural hospital CEOs worry any assistance may come too late.

"And yet I hear they're going to bail out the cruise lines? Really?" Missouri's Scotland County Hospital CEO Dr. Randy Tobler said.

As Tobler looks at his older, sicker, underinsured patient population, he said he is afraid the hospital, located on the state's northeastern rural border, might last only until May before running out of money for payroll.

"In the truly safety-net areas, we're being called to high duty," he said. "And we're running on fumes."

Michael Purvis, CEO of Candler County Hospital in Metter, Georgia, said he's already fallen into a negative cash flow situation in the past week. The number of patients coming to his hospital, which is about 65 miles outside Savannah, for profitable outpatient procedures has dropped by half as people in droves have canceled their surgeries, MRIs and physical therapy.

Purvis has implemented fever checks of people at the entrance. But he remains fearful that his billing staff could be forced to quarantine themselves if they fall ill — effectively shutting off the hospital's revenue.

"If my billers and coders stay healthy, I can make it to April, maybe end of June," Purvis said.

On top of the massive loss of revenue, Julie Jones, CEO at Community Hospital-Fairfax in northwestern Missouri, said she can only get specialty N95 respirator masks that offer critical protection for her front-line providers for about $5 each — more than 16 times the normal cost of 30 cents.

Angela Ammons, CEO of Clinch Memorial Hospital in Homerville, Georgia, said she has warned staff that if hand sanitizer and disinfecting wipes continue to go missing, she'll watch the video footage and fire on the spot anyone caught stealing supplies. And she is so worried about running out of protective equipment, she's asking any of her "crafty" staff with sewing machines to sew cotton masks.

"I would rather staff go in with a fabric mask than no mask at all," she said.

To be sure, rural hospitals are not as equipped as larger hospital systems to handle the most serious coronavirus cases. Many are not outfitted with ICUs or enough doctors and staff to handle multiple intensive care patients. That means they have to transfer those patients to larger hospitals.

Still, rural experts argue that their bed and health care capacity can be leveraged to keep potential coronavirus cases out of the major hospitals. Plus, rural facilities could be places for initial triage or eventual recovery care.

And if nothing changes, Rau worries, the country is about to lose this critical public health infrastructure.

"We can talk all we want about the cost of health care in this country in this ridiculous health care system we have," she said. "But at a time like this, who for a minute would think about getting rid of rural hospitals?"

[Correction: This story was updated at 9:25 a.m. ET on March 21 to correct the first name of the CEO of Clinch Memorial Hospital in Homerville, Georgia. Her name is Angela Ammons.]

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Mask Shortage Straps Pharmacists Who Need Them To Keep Medicines Pure

KFF Health News, March 20, 2020

A survey of hospital pharmacists found that 15% of them have already seen a "major or moderate" disruption in surgical mask supplies.

This article was first published on Friday, March 20, 2020 in Kaiser Health News.

By Christina Jewett and Sydney Lupkin, NPR News

Pharmacy staff who prepare IV drugs inside hospitals are the latest health care workers decrying a shortage of masks as they scramble to prepare medications for patients with everything from cancer to COVID-19.

The staffers wear surgical masks while preparing liquid medications injected into patients' veins to avoid breathing any droplets of saliva into the formulas, a crucial step in ensuring the medication remains sterile. Pharmacists are also in need of N95 masks to protect them as they counsel patients at hospitals — but tend to be behind front-line medical providers in line for protective gear.

The American Society of Health-System Pharmacists surveyed about 400 members about the shortages.

"I can tell you we had some very concerned members who indicated that they're in danger of running out," says Michael Ganio, a pharmacist and director of pharmacy practice and quality with the pharmacists' group. "Over half said their institution has implemented a conservation plan. It's something that's very concerning."

Medications that require sterile preparation include those needed for treating COVID-19 patients, such as medications to calm, sedate or paralyze patients on a mechanical ventilator. Other such medications could supply IV nutrition or boost the blood pressure of patients who develop sepsis or shock.

Geriatric and pediatric patients are also frequent recipients of sterile compounded medications because they need doses tailored to their weight or have age-related health problems that require specially made medicine they can tolerate.

The survey of hospital pharmacists, released Thursday, found that 15% of them have already seen a "major or moderate" disruption in surgical mask supplies. That meant they went without masks or used alternatives with "mixed or poor" results.

Nearly 20% of them reported that mask prices were marked up compared with December 2019. And 70% of pharmacists said their organizations had already implemented plans to conserve masks.

To be sure, these conservation efforts are more optimal for pharmacists, who use masks to preserve a sterile environment, than they are for front-line COVID-19 clinicians working in a contaminated environment.

University of Utah Health Hospitals are still receiving masks. But pharmacists are reusing masks for sterile drug preparation to conserve them for other staff members and patients who need them during the outbreak, said Erin Fox, senior director of drug information and support services at the University of Utah Health Hospitals.

"That will allow more PPE [personal protective equipment] to be available for front-line emergency department folks that need it way more than we do," she said, adding that there's guidance on how to safely reuse masks.

A tornado that cut through Tennessee this month is making things even more complicated in the state, said Mark Sullivan, the executive director of pharmacy operations for Vanderbilt University Hospital and Clinics in Nashville. That's because it damaged a warehouse that held hospital supplies.

"We are able to get masks," he said. "Given the tornado and coronavirus situation, they are obviously in short supply in our area."

Vanderbilt University Hospital and Clinics are also following guidelines for conserving masks and other personal protective equipment, like gowns and gloves, as demand has spiked, Sullivan said.

"It's just a tough situation we're all in, trying to make sure front-line folks have what they all need," he said. "And behind the scenes, we're just trying to make sure we have what we need to make safe products for patients."

Before coronavirus became a reality, pharmacists at NYU Langone Health used to change masks and gowns when they went out on break. Now, if that gear isn't soiled, they hang it up in a clean room and reuse it, said Arash Dabestani, the hospital's senior director of pharmacy. His team is also keeping all personal protective equipment in an electronically locked cabinet to control use.

For weeks, hospitals have been getting fewer masks than they ask for from their suppliers. Health care facilities were getting only 44% of the N95 masks and 82% of the surgical masks they ordered, according to a survey released March 2 by Premier, a group-purchasing organization that procures supplies for 4,000 U.S. hospitals and health systems.

Most of the masks sitting in hospitals are redirected to front-line staff who care for patients, said Soumi Saha, a pharmacist who is senior director of advocacy for Premier Inc.

Saha said many state laws require pharmacists to wear masks when mixing sterile compounds. Her fear, she said, is that if the mask shortage is dire enough, hospitals will move to an unregulated way to get those crucial medications to patients: bedside compounding.

That means that clinicians such as nurses would mix the medications right in the patient's room and put them straight into an IV, she said. She worries such a sudden shift means "we could start seeing a surge in unfortunate patient medication errors and patient harm."

Premier has asked the federal government to waive the state requirements on pharmacists wearing medical masks to mix compounds or allow them to use industrial masks or expired ones, Saha said.

For now, the choice is up to individual states, said Carmen Catizone, executive director of the National Association of Boards of Pharmacy. He said the national standards-setting organization that advises state boards, called USP, has urged states to make their own risk assessments when weighing whether to waive rules.

So far, California, Iowa and Connecticut have made moves to relax the rules for pharmacists' personal protective equipment.

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

A View From The Front Lines Of California's COVID-19 Battle

KFF Health News, March 19, 2020

Interviews with California physicians on the front lines of COVID-19 offer a sobering portrait of a health care system preparing for the worst of a pandemic that could be months from peaking.

This article was first published on Wednesday, March 18, 2020 in Kaiser Health News.

By Anna Maria Barry-Jester

On Tuesday, Dr. Jeanne Noble devoted time between patient visits to hanging clear 2-gallon plastic bags at each of her colleagues' workstations. Noble is a professor of emergency medicine and director of the UC-San Francisco medical center response to the novel coronavirus that has permeated California and reached into every U.S. state.

The bags were there to hold personal protective equipment — the masks, face shields, gowns and other items that health care providers rely on every day to protect themselves from the viruses shed by patients, largely through coughs and sneezes. In normal times, safety protocols would require these items be disposed of after one use. But just weeks into the COVID-19 pandemic, supplies of protective gear at UCSF are already so low that doctors and nurses are wiping down and reusing almost everything except gloves.

"It is not a foolproof strategy at all; we all realize the risk we are taking," Noble said. But as supplies dwindle, she increasingly finds herself asking the folks in charge of infection control at the hospital if they can make changes to protocols. "As days go by, one regulation after the other goes out," she said.

Noble is among the Bay Area physicians applauding the decision this week by seven Bay Area counties and multiple others across California to order residents to shelter in place for the foreseeable future, directives that are upending life for millions of people and shuttering schools and businesses across the state. Without swift and dramatic changes to curb transmission of the virus, hospital officials say, it is just a matter of time before their health systems are overwhelmed.

Interviews with California physicians on the front lines of COVID-19 offer a sobering portrait of a health care system preparing for the worst of a pandemic that could be months from peaking. In the Bay Area, the battle is being waged hospital by hospital, with wide variations in resources.

The tent where Noble tended to patients this week was set up to deal with a recent rise in people showing up with respiratory illness. Even without the coronavirus threat, UCSF's emergency room is a busy one, and doctors frequently see patients in hallways and other spaces. But the current outbreak makes that close contact unsafe. So instead, everyone who comes to the hospital is being triaged. Most people with fever, cough or shortness of breath are diverted to the tent, which is heated and has negative air pressure to prevent the spread of infection. For now, the pace is manageable, but Noble fears what's ahead.

Farther south, in Palo Alto, Stanford Medical Center was testing patients with respiratory problems in its parking garage. The private university hospital has more protective gear than the public one in San Francisco; a global scavenger hunt several weeks ago bolstered supplies, though Stanford, too, has adapted protocols to be more sparing with some items.

"We don't have an unlimited supply," said Dr. Andra Blomkalns, professor and chair of the Stanford School of Medicine's Department of Emergency Medicine. "But at least we're not looking at our last box."

The entire country is short on protective gear, a result of both the surging demand for such equipment as the virus spreads and the implosion of supply chains from China, where much of the equipment is manufactured.

Noble believes some equipment will need to be made locally. "If the [federal] government doesn't step in and force manufacturing of these products here now, we are going to run out," she said.

Empty supply closets affect everyone who needs care, including heart attack victims and people in need of emergency surgery, said Dr. Vivian Reyes, president of the California chapter of the American College of Emergency Physicians and a practicing emergency physician in the Bay Area.

"I know it's really hard for us Americans because we're never told no," she said of the shortfall of supplies. "But we're not in normal times right now."

And protective equipment isn't the only thing in short supply.

Until a few days ago, UCSF had to rely on the San Francisco Department of Public Health for coronavirus testing, and a shortage of test kits meant clinicians could test only the most critically ill. The situation improved March 9, when the university started running tests created in its own lab. First, there were 40 tests a day. By Tuesday, there were 60 to 80. But a new shortage looms: The hospital has just 500 testing swabs left.

Stanford pathologist Benjamin Pinsky built an in-house test that has been approved for use by the federal Food and Drug Administration. Since March 3, Stanford has used it to test more than 500 patients, 12% of whom had tested positive as of Tuesday. The university has been running tests for other hospitals as well, including UCSF. It's a dramatic improvement from a few weeks ago, when Stanford relied on its county lab.

Blomkalns saw a sick patient in mid-February, before the hospital had its own test kits, who had symptoms of COVID-19 but didn't qualify for testing under the narrow federal guidelines in place at the time. He went home, only to return to the hospital after his condition deteriorated. This time, he was tested and it came back positive.

In Santa Clara County, home to Stanford, 175 people have tested positive for COVID-19 and six have died. Late last week, the medical center's emergency department saw the highest number of patients in one day in its history. Blomkalns doubts it's because there are more cases in her area. "If you don't test, you don't have any cases," she said.

Blomkalns worries about staffing shortages as health care workers are inevitably exposed to the virus. As of Tuesday, one doctor in the Stanford ER had tested positive. At UCSF, six health care providers had.

Not all Bay Area hospitals are seeing a flood of patients. In fact, some have fewer patients than usual, as they have canceled elective surgeries in anticipation of a COVID-19 surge.

The doctors treating COVID-19 patients say nearly all who test positive have a cough. They complain of fatigue, body aches, headaches, runny noses and sore throats. While most people are well enough to recover at home, those who get critically ill tend to do so in their second week of symptoms, and can deteriorate very quickly, several doctors noted. "We are recommending that patients get intubated a little earlier than they might otherwise," said Reyes.

In general, officials are asking people who have mild cases of COVID-19 to treat their symptoms at home, as they would a cold or flu, and refrain from seeking care at hospitals. People experiencing shortness of breath, however, should definitely go to the emergency room, said Blomkalns.

For children, the criteria may be a bit different. Shortness of breath should trigger a visit, as should altered mental state, excessive irritability, or an inability to eat or drink, said Dr. Nicolaus Glomb, a pediatric emergency care physician at UCSF Benioff Children's Hospital.

Gov. Gavin Newsom said Tuesday that rough projections suggest the state could need anywhere from 4,000 to 20,000 additional beds to treat patients with serious cases of COVID-19.

The testing problems worry Noble, as do the equipment shortages, but not nearly as much as the potential for a lot of sick people. "I'm mostly worried about a tsunami of very ill patients that we're not equipped to take care of," said Noble.

Blomkalns isn't sure whether or when Stanford might exceed capacity, saying the caseload trajectory may hinge on how aggressively state and national authorities move to cut off routes of community transmission. "It all depends on what happens in the coming weeks and days," she said. "We know what we need to do, and we're doing the job."

KHN Senior Correspondents JoNel Aleccia and Jenny Gold contributed to this report.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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