Is the county keeping track of workplace outbreaks? How many Granada residents will die? Are medical staff being tested often enough? Is the trigger for the state’s new stay-at-home order — less than 15 percent of ICU capacity — actually too lax? Are there enough people to staff all our ICU beds?
Dr. Josh Ennis, deputy health officer, answered these media questions and more in today’s media availability on the county’s COVID response. Video above, rough transcript below.
The North Coast News asks, “Are county health officials keeping track of the number of workplace outbreaks, defined as three or more cases within 14 days, and can you share this number with us? Are you able to share a list of which workplaces specifically have had outbreaks?”
For every single positive case that we get we reach out to the individual, we get information regarding potential exposure, define the infectious period, investigate places of employment as well, because there are some new mandated reporting requirements surrounding exposures in the workplace.
We don’t keep track of outbreaks in the way that this question is worded, but we do keep track of where exposure events occur and many times that is in the workplace setting. Suffice it to say it is truly in a large number of settings and in the highest-risk settings such as nursing facilities, assisted living, as well as health care settings. We have more than five across some of those settings ongoing right now. Just to give you an example of what we’re up against right now.
In many of those settings we’ve been very successful at containment, but not successful in every single one of those cases, so this is what we’re battling against and it’s challenging to respond to every single one of these situations and test hundreds of people on a once or twice weekly basis. That is how widespread the disease is right now.
The North Coast News asks, “When a county resident is tested are they asked for their place of employment and is this documented? If not, why?”
So I spoke to this already in the first question but we typically get this information at the time a positive test comes in, so we don’t ask for it up front, we’re testing thousands of people in any given week, and so it’s when we have a positive that we reach out to individual, ask about places of employment, to determine if there’s any exposure potentially within that workplace setting, and then it goes out from there through the tracing. So we ask for it after the positive comes in and not up front at the time of testing because it’d simply be too much information to manage when we’re testing thousands of people every week.
The North Coast News asks, “With community transmission at an all-time high do you believe focusing on stopping spread of COVID-19 in the workplace is still as effective in mitigating spread in the population as it was earlier on in the pandemic? Has stopping workplace spread become more or less of a priority for Public Health?”
I think we are more effective in mitigating transmission in the workplace setting but given the volume it’s become increasingly challenging to always contain it 100 percent of the time because our resources are spread thinner and thinner.
There’s no explicit statement that we’re placing more priority on the workplace setting, although we’ve seen lots of the regulatory environment around this get tightened up at the state level, but I will tell you because of the shift we made some time back in our investigations and tracing to having certain priority groups that are higher risk individuals or higher risk for widespread spread of disease, it is inherent in the priority groups that we put together that we do focus on some workplace scenarios where there is a lot of potential for widespread transmission of disease.
And again I’ve said this about the nursing facility setting, but anytime there’s a workplace setting and there’s a big outbreak within it, it’s not isolated to that facility because people are coming in and out all the time of that system, so there’s a huge potential for it to reflect back out in the community and while I wouldn’t call it necessarily a super spreader event, it’s working in much the same way, spread out, drawn out over a period of days to weeks, so it’s a big concern anytime we have a large outbreak in any of these settings and the workplace is no exception.
The North Coast News asks, “Do you agree with the new requirements for employers laid out in Cal/OSHA’s emergency temporary standard?”
Early on in the pandemic we set up the business approval process through our county EOC and Joint Information Center, and so many employers already have kind of the framework of what’s being asked for here, and we’ve seen that there is a lot of potential for spread to occur in the workplace setting on account of concerns about retaliation in the workplace setting, a potential loss of short-term income and ultimately potential loss of long-term employment if that person’s potentially easily replaceable in the workplace setting.
So I think the idea here is to make it easier for people to come forward have a plan in place to deal with it quickly and try and limit the spread of COVID-19 in the workplace and the reality is we’ve been doing this all along this is just formalizing kind of the regulatory environment around it.
The North Coast News asks, “What is the realistic expectation for loss of life at Granada considering many residents have opted to not have extreme life-saving measures taken? Can they change their minds on the DNR paperwork considering many signed it pre-pandemic?”
So when a patient comes to a nursing facility their code status or end-of-life wishes need to be evaluated and they need to be known upfront and that’s reevaluated on an ongoing basis.
When we look at who actually is in a nursing facility, they tend to be people who are older and who have comorbidities that make them more dependent upon 24-hour nursing care, and that’s the definition of a skilled nursing facility.
So these are the two things that we know place those individuals at the highest risk for severe disease, as well as death, and so we know that when there’s an outbreak in the nursing facility that there is going to be a lot of loss of life, and it’s where approximately 40 percent of all deaths were occurring early on in the pandemic.
None of them are forced into any end of life decisions last minute. They can have a discussion surrounding any changes they would like to make, so it’s not something that’s written in stone, it can be reevaluated at any point.
The Redheaded Blackbelt asks, “Since the state issued the mandate for weekly testing of all hospital staff, which includes support staff and delivery personnel, as well as staff that are in direct contact with patients, has St. Joseph Hospital in Eureka implemented this process, and if not what are the hurdles to getting this done? Alternatively, if you are aware that they have been doing this on a weekly basis, how many tests are required to test the entire hospital staff?”
First I’d like to point out that this is not actually a mandate, it is a recommendation at this time.
Secondly, this was a timeline that tried to put this all together in a matter of two weeks and we’re talking about thousands of tests a week across the entire county. Seeing how the testing landscape has been, where it’s where it’s been throughout the entirety of the pandemic, making another 2,000 tests available, 3,000 tests available in the matter of two weeks, is simply impractical.
We’ve been working 10 months to get where we’re at now of being able to do somewhere around four or 5,000 in a week, so the hospitals are making their best effort and a good faith to meet this recommendation, but it’s simply impractical to make it happen in a matter of two weeks, so we’ve been trying to make it much more targeted but support the hospitals in trying to meet this recommendation.
The Redheaded Blackbelt asks, “Due to the need for COVID-19 positive patients to be coordinated together and isolated apart from other non-COVID hospitalized patients, how many ICU beds are designated to the COVID unit currently in light of our recent increase in hospitalizations?”
So I want to clarify one item here because this question’s asking about the COVID unit, so I’m guessing they’re speaking to the COVID unit that’s been established, or the respiratory care unit that’s been established at St. Joe’s Hospital in Eureka.
They do have dedicated space for those patients but that does not overlap, is my understanding, with the actual ICU.
What’s really important in caring for COVID-19 patients is that to minimize risk of exposure to those staff caring for the individual, they need to have negative airflow and so there’s a certain air volume that needs to be exchanged in a certain period of time and those rooms exist elsewhere in the hospital, they’re not exclusive to just the COVID unit, so they have Med Surg rooms, they have ICU rooms that have those air flow capabilities, and so the patients can be cared for outside of this respiratory unit, it’s just the unit itself tries to bring together all of it in a more centralized fashion to make caring for these patients easier and safer on the whole for the entire staff.
The North Coast Journal asks, “In other parts of the state, doctors and hospital administrators have raised alarm bells about whether the state’s ICU capacity metrics used to trigger the governor’s stay-at-home order fully take into account staffing and other limitations. Do you feel like the state’s regional ICU capacity database accurately reflects hospitals capacity to provide intensive care?”
The regional ICU capacity metric across Northern California doesn’t reflect how patients move throughout the health care system.
As an example, Humboldt as well as counties to our south typically send patients south to the Bay Area or east over into the Sacramento Valley, Del Norte sends into Southern Oregon, the north eastern corner of our region sends into Reno, so patients move throughout the health care system and it’s not captured fully by this regional metric.
Secondly, the regional metric has maybe a little more than 100 beds, but if you compare to that to receiving hospitals such as Bay Area and Sacramento, we’re only a tenth of what the Bay Area has and we’re only about a fifth of what the Sacramento Valley has, so we have a very small sliver of the overall ICU beds that our patients may end up occupying. So while our percentage looks good locally, it looks good across the region, it may not take into account the context of where the patients move outside of our region.
The North Coast Journal asks, “As of this morning the county’s dashboard shows Humboldt County hospitals have 50 percent available ICU capacity. Can you explain what metrics are used to determine this percentage? Is it simply licensed beds that are currently available? Does it take into account hospitals’ emergency plans to create more surge capacity? Does it account for available staffing under current conditions with traveling nurses largely unavailable?”
So there has been no shortage of confusion about this because the way it’s been looked at has changed several times throughout the pandemic. It is not using licensed beds. Licensed beds across the state typically include neonatal ICU beds, they include pediatric ICU beds in our county, and I believe there are five neonatal ICU beds that are included in that number, so it’s kind of misleading, you can’t put a 60-year-old in that neonatal ICU bed.
So what they’re looking at are the adult ICU beds that are part of what they term as non-surge operations, meaning they can bring the staff and the equipment in as part of their regular resources.
So they basically look at the empty adult ICU beds and put that on top of how many non-surge adult ICU beds are look and calculate that percentage of available ICU capacity. Again our numbers are very small in our county and our region compared to many of the receiving regions that may have our patients getting sub-specialty care that they can’t otherwise get in our county.
The North Coast Journal asks, “In a county like Humboldt with comparatively fewer ICU beds per capita than more urban areas and understanding hospitalizations generally trail two weeks or so behind new confirmed cases, is the 15 percent threshold an early enough trigger to effectively implement new restrictions that would prevent the local hospital system from becoming overwhelmed?”
It really depends upon what’s happening around us whether that 15 percent threshold or trigger is appropriate. I can tell you that as I’ve already talked about some of our other regions that may receive some of our patients — The Bay Area has more than 1,300 ICU beds, the greater Sacramento region has more than 500 and the Nor Cal region, just to put in perspective, has somewhere between 120, 125 ICU beds across our region. So we hold a very small sliver of the entire pie of ICU beds that may care for Humboldt County residents.
So if they’re impacted dramatically all around us, it may not make sense to wait until we reach this trigger because we’re talking about a very small number of beds and as we’ve seen with small numbers, they can fluctuate a lot and so it may not make sense if what’s going on around us is dramatically impact and full already.
The North Coast Journal asks, “There has been a lot of talk about securing additional ventilators and building ICU surge capacity in local hospitals, but a ventilator in a hallway isn’t really an ICU bed and a ventilator alone won’t save lives if there isn’t a trained professional ready to staff it. How many patients would you estimate Humboldt County’s health care system can provide with intensive care at one time before the hospital becomes taxed and the quality of care decreases?”
So there has been a lot of focus on this because it is our most limited resource and no one wants to be forced into position similar to wartime medicine where you’re having to choose who gets the vent, who gets the ICU bed.
This question is correct though that if we’re reaching a point where there aren’t enough people to care for all these, the quality care is going to suffer.
So we’ve focused on these limited resources, we’ve increased them substantially, both ICU beds and vents to a point where other issues are probably going to come into play, such as the health care workforce, before we actually reach the hard cap of these finite, limited critical care resources.
So I’d be hard-pressed to give a number at this time because it changes depending upon the demand for this healthcare workforce elsewhere.
In Humboldt County we do have a need for traveling health care professionals and if they’re in demand across the entire country at the same time we’re going to have a much more challenging time bringing them in to deal with the surge.
So the actual number can fluctuate depending on what’s happening around us and right now they’re in peak demand across the state, across the entire country.