Nuvance Health, a seven-hospital system just an hour away from New York City, has seen a dramatic spike in COVID-19 cases in the past two weeks. When we first spoke with President and CEO John Murphy, MD, his hospitals were just beginning to see an increase in patients with COVID-19. Twelve days later, we talked with Murphy again to understand what has changed and find out how his organization is preparing to fight a predicted surge in cases in early April.
In all Kaufman Hall interviews, the expert opinions expressed are those of the interviewees and should not be considered opinions of Kaufman Hall. This interview was conducted on March 27, 2020.
Q: How has your volume of patients with COVID-19 changed during the past two weeks?
A: Our first case was not quite two weeks ago. Today, the number is more than 200. Cases have increased by more than 150 percent in the past seven days.
Keep in mind that we are becoming increasingly stringent with our admission criteria because we have to be mindful of our bed capacity. We have canceled or postponed all non-urgent surgeries to create bed capacity. And if there's any way we can get a patient treated at home, we do that. So when I say we're up by 150 percent, that includes people who we think can be managed safely at home. Ordinarily, we probably would have admitted them.
We’re finding that some patients we think are on the mend suddenly come back because their respiratory status has decompensated or worsened, so we are being careful to avoid prematurely discharging patients. The numbers are growing, and the number of patients requiring ICU beds and ventilation is growing.
Q: What else have you learned from treating these patients so far?
A: At the moment, about one-third of all patients who are inpatients with COVID-19 need to be ventilated. That's higher than we thought would be necessary.
We're also learning that the virus is following a different clinical course than a typical community-acquired pneumonia. We are seeing these patients present with lower oxygen levels and more rapid decompensation. Typically you can assess the hypoxia in pneumonia patients and can predict where their oxygen levels are going to be in 12 hours, 24 hours, or two days. But we’re finding that these Covid-19 patients can decompensate fairly precipitously, so they require more frequent monitoring and an earlier threshold for intubation.
Also, the notion that this only happens to older people is not entirely accurate. We have intubated patients in their 30s, and 40s just this past week. That was not what we were expecting based upon literature from different places around the world.
And not everybody has the same presentation. We assumed some older patients who didn’t have fevers weren't infected—we thought this was just the decompensation from their chronic heart failure or simply a urinary tract infection. But, in fact, they're turning out to be COVID-positive. So we are broadening our surveillance and testing patients who are decompensating for COVID infection.
Q: Has testing improved on the front line?
A: Testing is a real problem. This isn't unique to us. I'm sure it's true of other organizations.
We are acquiring samples without difficulty on an inpatient basis, and we're probably testing almost 1,000 people a day on the outpatient side in our various hospitals. The concern for those who are on the inpatient side, however, is turnaround time. It can be three, four, or five days before we get the test results back. And that places a real burden on the staff as well as on the supplies because you have to continue to treat those individuals as potential COVID infections.
Point-of-care testing hasn't made it here yet, and that's a challenge because we want to know how to cohort these patients. We have multiple COVID units now, including COVID ICUs where it's a single, negative-pressure environment. The staff can protect themselves with appropriate masks and gowns, etc., and then freely deliver patient care, as opposed to having to don and doff their personal protective equipment because one room has a patient with COVID and another room does not. We could do that much more efficiently if we knew in real-time who was infected and who wasn't.
It also would be nice to know in real-time who among our healthcare workers has a COVID infection. We have a couple of nursing homes where we have significant outbreaks, and it would be helpful to have a rapid sense of who's infected there and who isn't.
Q: How are you screening staff?
A: We still have more than 100 employees who are out on furlough because they may have been exposed or were exposed to somebody infected with COVID.
We now screen employees as they come to work, whether they have been in contact with anybody with a COVID infection or they themselves have symptoms or a fever. We screen for temperatures at every entrance at every hospital.
Q: What do you expect the next two weeks to look like?
A: As we've now done thousands of tests in the community, the positive rate is hovering around 25 percent. That's much higher than we thought it was going to be. That’s why we think we need to get ready for a surge.
I spent a fair amount of time during the past four or five days looking carefully at a model that provides us with a look ahead, based upon a few key assumptions. We’re looking at the doubling rate and how many more patients are coming in day to day. We’re looking at the prevalence in the community with outpatient testing. And of course, we're in New York state, which has more cases than anywhere else in the United States, as well as in adjacent Connecticut. We're also looking at our length of stay in the ICU, which is just about 13 days—far shorter than what was reported in China. That's a break, although many more patients need ventilators than we originally expected.
With all of those various calculations, as well as calculating the mortality rate, we're trying to figure out how many people will likely come in with COVID-19 next week. We’ve shared our model with the states of Connecticut and New York, and looked at their models. That is a sobering exercise because I would not characterize myself as an alarmist in any way but rather a data-driven guy. The data is clearly a very serious concern. On a daily basis, we look at how many people with COVID or suspected COVID are in our beds, how many are on ventilators, and how many ventilators we have left.
We think we're probably 10 days away from a real spike, but that spike is going to be a big deal.
Q: What have you done to prepare for what lies ahead?
A: We have already begun to move ventilators to at least two of our hospitals. We also have to be sure that we can adequately staff all of the ICU beds and care for patients who need to be mechanically ventilated.
And we have more than doubled our ICU capacity by basically clearing out beds and converting outpatient treating rooms, cath labs, and recovery rooms. We're trying very hard to find rooms that have medical gases and make them ICU beds. Our top priority has to be those patients who come into the hospital and need mechanical ventilation or might need mechanical ventilation.
Beyond that, we have committed that we will increase our medical/surgical bed capacity. Our governor in Connecticut said based on their models, 50 percent additional capacity will not cut it, so now we are shooting for at least 60 percent. We have put up a field hospital on one of our campuses and have just gotten the state's approval to put it to use now. The National Guard did a terrific job, as did the state department of health, in getting it up quickly and providing us with the necessary waivers to put it to use.
Now we're looking at alternative sites that include local gymnasiums and community colleges. There's a large Portuguese cultural center here where we think we could probably put a couple of hundred beds. We’re also looking at more distant facilities as potential medical shelters for patients who aren't going to need intravenous medications or oxygen yet aren't well enough to go home.
One issue we need to consider with these alternative sites is privacy. Can we split the sites to respect the modesty that men and women both deserve? We have more men than women infected with the virus, so we need to cohort them with that in mind. We also need to provide fresh water, toileting facilities, food, and safety. This isn't stuff we typically have to think about. But today we had to present our governors with detailed plans for each facility.
Q: What other resources are you trying to secure to address a surge in patients?
A: We're trying to order used beds. As of today, March 27th, we couldn't find any beds to rent, so we're now scouring the country looking for used beds.
Masks and gowns are another issue. As of today, we have 13 days’ worth of masks. That's not going to be enough. It just won't be. We have adopted stringent mask conservation programs to collect used masks, particularly used N95 masks, and are studying how to disinfect those so that they can be safely reused. And we’re obviously trying very hard to look up and down the supply chain and around the world for N95s, industrial N95s, and isolation masks.
We're not alone in this. Everybody's doing the same thing. Masks are certainly a concern, gowns are a concern, and medications are a concern. Everybody's interested now in hydroxychloroquine and azithromycin. We have a decent supply, but we'd like to give everybody the benefit of medications. We were fortunate enough to get in on a trial of remdesivir, which appears to be a potentially effective antiviral medication.
But the issue that keeps me up at night is the ventilator supply. We increased our ICU capacity by 100 percent, but we haven’t been able to double the number of ventilators. We have been working around the clock to try to find all the ventilators we have in our own facilities and make them available. And we found out that some ventilators in the OR, which are typically used for two hours at a time, can't run 24 hours a day for 13 days.
I was just on the phone with one of our U.S. senators asking him about access to a federal stockpile. But I don't see any new ventilators coming our way in the short term.
So we've had to make some modifications and carefully examine how to deploy those ventilators. We're reaching out to our partners in the community who run and operate ambulatory surgery units to access their ventilators. And all of our ICUs are prepared to split ventilators. We haven't done it yet, but if we have two people of the same size and roughly the same lung capacity, we can put them on the same ventilator. I hope it doesn't come to that, but I would much rather do that than deny someone access to a ventilator who needed it.
We’re also carefully looking at what we can do to reduce the need for ventilators, perhaps by shortening the length of time people are on them.
Q: What other challenges have you faced?
A: A difficult but necessary topic to talk about is having an ethical framework in place if and when we need to allocate scarce resources. We have done it quietly with our ethics committee. We've invited board members, clergy members, ethicists, physicians, and nurses, to look at a policy that we have developed in concert with other state policies and ethical guidelines.
I would like to do it thoughtfully and ask our medical executive committees to think about this, and then I hope and pray that we never need it. That is something that we are in the midst of now.
Q: What support have you received from your communities, and what message do you have for them?
A: Our communities have been extraordinarily generous. We've had donors offer us money without asking. Businesses have been donating supplies. Restaurants are providing meals for the staff. Local residents are offering to sew masks. Colleges are offering their dorms. Elected officials are putting aside politics and trying to find solutions that demonstrate their commitments. The clergy are asking how they can help us—we had a gentleman have last rites by FaceTime the other night, and the family actually said it was beautiful.
To help the communities get through this with as little mortality and morbidity as possible, I hope we can somehow flatten that curve that we've all read about. I hope that we can meticulously follow all of these public health measures—including social distancing, proper testing and isolation, quarantining, and hand-washing—so that we can flatten the curve and either postpone the surge or decrease its peak. Then we will be able to handle the number of patients who need our services and who need to be hospitalized.
Q: How do you balance between the desire to reopen the economy and the need to control this virus?
A: All the models that we have looked at have identified the second week in April as when our communities get into trouble. I'm hoping that if we can manage that first week and reach a plateau in that volume, we will just hang tough for as long as we can. But if it continues to rise well above that, we don't have the capacity. We don't have the people. We don't have the equipment or the supplies to manage that.
I would err on the side of trying to do everything we can to keep the level of infection as low as possible so that we can serve the people who need to be hospitalized. My view may be skewed by the fact that I'm in healthcare. Other people may say damaging the economy is going to cause unemployment, which causes its own set of hardships. I recognize that, but we're talking about avoidable death here, which I think is a higher priority than an economic concern. I just don't see April as a realistic target for relaxing our position on public health measures.
Q: As a CEO, how are you trying to lead your staff during this difficult time?
A: I want to salute our staff and acknowledge their remarkable courage, their resolve, and their commitment to show up for work despite the real risks to their own health. They're showing up for work every day, donning the appropriate equipment, and providing great care. Not only am I deeply grateful for their efforts, but also the entire community is showering them with praise because they're heroes.
Our organization is filled with good people experiencing a wide range of emotions, including a certain level of grief that is very real. We are seeing a number of deaths that are not typical. There is certainly a degree of anxiety and even anticipatory anxiety about what might be coming, which is why I'm pretty careful with sharing some of these models.
One of my jobs as CEO is to try, if possible, to manage the level of anxiety in an organization and not allow a sense of despair to creep in. I don’t want to concentrate so much on the things we can't control, but rather remind people of the things that we can control.
We have all been trained on how to deal with infectious diseases, and if we follow protocols, we'll do our level best. I'm working hard to try to deliver that message to the organization, not only by what I say, but also by how I act. And we can't wait until we get to the other side of this.