In TV’s “Game of Thrones,” characters bleakly observe: “Winter is coming.” In this county a viral storm is coming that has only just begun to materialize—even though for two weeks we have been sheltering-in-place awaiting its arrival.
President Trump solemnly declared Tuesday afternoon, “I want every American to be prepared for the hard days that lie ahead. This is going to be a very, very painful two weeks.” It is likely that the worst of the pandemic hasn’t begun to hit San Diego County yet.
Early warning gave a head start
Every three days the numbers of those infected with the coronavirus in San Diego County doubles. So that the number of persons identified with the virus as 734 at Tuesday’s County briefing can be expected to reach 1,500 by the time you see Thursdays paper—and 3,000 by the beginning of next week.
Such exponential growth tends to make the short neck hairs stand on end. Especially since nine people have died from COVID-19 since it was first identified here.
What is not widely known is that San Diego medical officials had an early warning several weeks ago when the first quarantine patients arrived. This gave them a head start that many other cities did not have.
I spoke Monday with Diane Hansen, president and CEO and Dr. Omar Khawaja, Chief Medical Officer of Palomar Health about how prepared the system is to handle the outbreak.
Hansen said, “We have been planning for some time as we saw this ramp up—not only within our national borders, but internationally. We began making plans and preparations as early as January and February. Talking about—if it were to come to San Diego—specifically to our district—what would we need to have in place?”
They spoke, not only with local officials, but with state and national health officials as well. “We have ongoing calls with everyone so we can stay aligned, not only with what is happening in Escondido but the County and the state,” she said.
Dr. Khawaja added, “We have an emergency preparedness team that works with different governmental agencies to build out plans for all sorts of contingencies. We have emergency supplies and equipment. That infection control team learned a lot when we dealt with H1N1 (aka the “Swine Flu”) which hit Escondido very hard (in 2009.)” He added, “They always have a plan in place and have sharpened their skills with other outbreaks. So it was faster than starting from zero and ramping up.”
As of Monday morning (Remember, this is a moving target, so when you read this the figures will be different) they had tested 766 patients and had positive results for 22 individuals. These figures are from both Palomar Hospital and Palomar Poway Medical Center.
A faster test
Dr. Khawaja said, “We have a tent set up in front of both hospitals. It is actually a lot of walk-ins. A good number are referred from their primary care physicians. They walk in and are treated and tested in the tent. The vast number are going home. Of those 22 positives, only four are still actually in our hospital. Most are tested. Their symptoms are seen to be not life-threatening. They are sent home and wait for test results.” He added, “We aren’t seeing a lot of ambulance or emergency drop offs. This is more people coming in and feeling ill, knowing that their symptoms that are similar to COVID from the news media—coming in and being isolated and tested.”
It has been taking, on average, five days to get test results. “But we recently partnered with Rady’s Children’s Hospital,” said Hansen. “They are turning tests around for us the same day. That just occurred the end of last week. We were able to clear a lot of patients quickly. ”
Note: Earlier this week the medical company Abbott received emergency use authorization (EUA) from the U.S. Food and Drug Administration for the fastest available molecular point-of-care test for COVID-19, delivering positive results in as little as five minutes and negative results in 13 minutes. That is not the test Palomar is using, but indicates the level of intensity the medical industry is applying to this problem.
“We are going to have our own rapid testing up and running by the end of this week,” said Hansen. “We will be able to do that testing inhouse ourselves.”
Dr. Khawaja added, “For that, there are a limited number of tests. We are prioritizing. Outpatients will still be a 5-7 day turnaround, but we will have our own tests for the sickest patients. That will have same day turnaround.”
Keeping employees, patients safe
Given that the old Palomar Hospital still hasn’t been demolished and has a capacity to house beds, will they be using any old rooms? “We have been in many conversations with the County and most recently the State about potential use at this campus, located in downtown Escondido,” said Hansen. “Nothing has been finalized yet. Just the awareness that we are in conversations. And yes, should that be necessary, that will be a lever we pull.”
How do they prevent the spread of the virus inside the hospital? “Keeping our patients and employees safe is of the utmost importance to us,” said the CEO. “We’ve taken a number of steps—and quite honestly we’ve changed directions as well as this virus has progressed. We have watched closely the temperature testing of anyone who comes in the doors and we are masking those individuals as they come in.”
She added, “Originally we wanted to limit the PPEs (Personal Protective Equipment) and we are still trying to manage our supplies as diligently as we can. We are also doing everything we can within the walls of the hospital to separate patients appropriately. To ensure that our nurses have the appropriate protective gear and we are all sanitizing, washing our hands and social distancing to the extent that we can.”
Dr. Khawaja continued, “In general, it starts with your process for these patients. That they are identified outside of the hospital in a tent, in a separate area where the nurses and staff have the highest level of protection with their personal protective equipment. Once they are decided to be a suspect of COVID they are isolated in negative pressure rooms. Again, all of the highest level of PPE is placed for that staff.” These include shields, masks, gowns and gloves that you see in the photo for this article. The full outfit.
Hansen continued, “Dr. Khawaja and I rounded on some of our nurses yesterday. I was really pleased to hear that those nurses taking care of the COVID possible patients awaiting results felt really good about their protective equipment and that they had the right things they needed.”
The nurses told Hansen and Dr. Khawaja “ ‘We feel pretty good right now and we feel we have the right equipment to protect us.’ It was a good conversation to have with them because it is important for them to feel confident as they take care of these patients that they are not going to get the virus,” said Hansen.
Negative pressure rooms
The hospital staff is taking extensive steps to segregate COVID patients. “We’ve actually created quite a few additional negative pressure rooms,” she said.
Dr. Khawaja interjected, “With the small numbers we are seeing right now, we actually don’t have enough to create a full ward of COVID or COVID possible patients. We have placed them into individual rooms that have negative air flow. It is sucking all of the potential virus out of the room and exhausting it outside of the hospital.” He added, “Our facilities team has done kind of a magic job of spinning up these rooms so we are able to put each patient that is isolated and separated into their own individual negative pressure room. The work they have done is particularly astounding and creative.”
They have 54 isolation rooms capable of having negative pressure at the Escondido campus and 29 at Palomar Medical Center Poway.
Having enough respirators
Palomar Health constantly monitors how many respirators it has and if that is enough, especially as the number of patients testing positive climbs. Hansen said, “Right now throughout the health system we have roughly eighty ventilators. We just ordered another thirteen that we should have within the next two to three weeks.”
That’s not as few as it seems. “The best thing about our equipment,” said Hansen, “and that is not true of every ventilator we have— we can hook up as much as four patients to a ventilator. The capabilities are much higher than just the number of ventilators that we have.”
Dr. Khawaja said, “When you are talking about crisis planning; we are being incredibly creative with lessons learned from countries and cities that are being very hard hit. This is something we found on the internet from the Italy experience. We tested and piloted it in our facility. We have not hooked up more than one patient to a ventilator. We have done a proof of concept where we could do that if and when the crisis comes.”
Asked if they are working with local companies for equipment or to sanitize masks more than once, Hansen answered, “We haven’t taken some of those extreme steps at this point to sanitize masks. There is a conversation at the county and state level how effective that is and whether it really provides the most protection possible.”
She added, “Some of those ideas are being vetted by people more knowledgeable about that than I am. I think everything is on the table and to the extent that if it works we will be part of that conversation at the County and the state level and we will put those measures into place.”
Sourcing needed supplies
Dr. Khawaja added, “The place where we have the most cooperation is sourcing from corporations that provide us supplies. Multiple corporations have reached out to us that have connections to source supplies for us. We tracked down leads from places like Mexico and China for supplies. Right now, we have tracked down at least 120 different leads from the community and different businesses looking to source equipment in the most creative ways possible.”
Hansen said, “We are doing everything we can to source supplies from a variety of suppliers. Not just within the county and the state but across the nation, across the globe. That is how we are trying to keep up with demand. Make sure we have enough protective equipment for our staff and our patients. It’s difficult. There are a lot of scams out there. It takes a while for our supply team to vet those. By and large, right now we feel we can be successful at continuing to keep a supply of the equipment we need.”
Dr. Khawaja added that the County’s crisis planners are looking to reuse and recycle equipment and supplies. As we take guidance from them we are in those conversations and will take all necessary steps if this truly becomes a crisis.”
This prompts the question: Are there bottlenecks in getting respirators and news masks? Hansen said, “Absolutely everything you have heard as regards to masks and swabs and ventilators [is true.] We’ve been working on this at least the last month to get as many orders out and secure as much as we can in terms of masks and ventilators. It’s tight but it means we need to manage on a daily basis. We have a supply list that comes out daily. We manage to that supply list and the number of days’ supply. For example, on masks we might look and see we have 18 days of supplies based on our current use rate.”
Hansen added, “We’ve been able to tighten those numbers down by just managing our supplies more closely and putting more security measures in place so we have the appropriate personnel handing them out to nurses, doctors and patients that need them. By and large, it’s really just making sure we are as smart as we can be about the utilization and deployment to those who need them.”
There has been a lot of talk—Much of it by President Trump—about using the old anti-malaria drugs and Chloroquine and Azithromycin to treat COVID-19.
Dr. Khawaja said, “There are two medications. One is an antiviral that there isn’t a lot of data on. On the antimalarials Chloroquine and Azithromycin: we do have a very strong pharmacy and infection control partnership with an infection control pharmacist who has built out a protocol for that. We are using it on those we believe really need it because the data is very minimal and the medication does come with some very prohibitive side effects. We treated one patient with that regimen, and they seem to be responding well. It’s still early days and it’s still very new to us. Normally we would be testing these medications three to five years before rolling them out but these are unique times.”
Hansen concluded, “We are working very hard to take care of the patients and the families within the district and county. We’re here, we are ready and we are prepared to take this on should it transpire as they expect it to.”
Dr. Khawaja added this final note: “It’s very important for people to know that Diane as CEO is very involved in conversations with every CEO in San Diego County along with the County health leadership as well as with state officials. She has been able to connect with a lot of the resources that we need to treat the patients the way they need to be treated. That’s important for people to understand how much work she is doing.”