COVID-19: Report from California

COVID-19: Report from California

Coping With COVID-19

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.

Waging the Battle, Hospital By Hospital

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.

Looming Shortages

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.

COVID-19 in CA: The Symptoms They’re Seeing

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.

Reposted courtesy of Kaiser Health News, a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Hospitals in CA, Other States Start Canceling Clinical Training

Hospitals in CA, Other States Start Canceling Clinical Training

Yet another casualty of the COVID-19 pandemic may be the clinical training that’s so essential for America’s future nurses and doctors. 

As university campuses close and disease prevention efforts intensify, hospitals, nursing homes and other health care venues in California and nationally are canceling clinical rotations for student nurses — and, in some cases, medical students. The rationale is to protect both students and patients from getting sick and to reserve personal protective equipment, including masks, that may be in short supply. 

But medical educators worry the students won’t get the hours of direct patient care experience required to graduate on time, slowing the pipeline of new health care professionals precisely at a time when the country may need them most. 

“We are in unprecedented times,” said Dr. John Prescott, chief academic officer of the Association of American Medical Colleges. “Medical education hasn’t faced anything quite like this since the beginning of the Second World War.” 

The risk that hospitals and other health care facilities fear was underscored this month when an instructor was diagnosed with COVID-19 after bringing a group of nursing students to the Kirkland, Washington, nursing home where at least 63 residents have been stricken by the illness — 29 of them fatally, as of Monday afternoon. Those students are now in self-quarantine. 

On March 5, Kaiser Permanente requested that nursing schools temporarily discontinue student clinical rotations in its 21 medical centers in Northern California. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.) “We are in a dynamic situation and our highest priority is ensuring the safety of KP members, staff and students participating in clinical training,” a Kaiser Permanente executive wrote in an email to the nursing schools obtained by KHN. 

A spokeswoman for the health system, which serves 4.4 million Northern Californians, confirmed the cancellations. 

Two other large hospital chains in California, Adventist Health and Dignity Health, soon followed suit. 

As a result, the nursing schools at the University of California-Davis and Samuel Merritt University have had to scramble to find new clinical training opportunities for dozens of students. Some landed at the University of California-Davis’ medical center or clinics and others at Veterans Affairs hospitals. 

Nursing education leaders in California appealed to the state’s Board of Registered Nursing on Thursday to ease the number of on-site clinical hours required for student nurses to graduate and allow them to learn from simulations instead. 

State law requires nursing students to receive 75% of their clinical training in health care settings such as hospitals or nursing homes approved by the board; only 25% can be completed using simulations, such as computerized mannequins. The educators, in a letter to the board, requested that students be allowed to do 50% of their training through simulation. 

“Many schools in California are experiencing serious clinical displacement. The effects of the lost clinical hours will be devastating to the students we serve,” more than 60 officials from community colleges and nurse training programs around the state said in the letter. 

As of Monday, Board of Registered Nursing officials had not responded to a request for comment. 

Even before the COVID-19 pandemic, some private nursing schools had pressed state regulators to allow more simulation training, arguing it has advanced to the point where it can be as effective as training in a hospital or clinic. 

The move to cancel clinical training is the opposite of what happened during the 1918 flu pandemic, when student nurses were called to hospitals to care for patients. Some fell sick and died along with those in their care. 

Most hospitals have not canceled clinical rotations for doctors-in-training, but some have, and Prescott, of the Association of American Medical Colleges, said more may do so in the coming weeks. 

On Thursday, the University of Arkansas for Medical Sciences asked all its students to immediately leave their clinical rotations to prevent the spread of COVID-19. The University of North Carolina School of Medicine canceled clinical rotations for visiting students from other medical schools from March 30 to April 24. 

The University of Pennsylvania has suspended clinical rotations for some medical students, as has the University of Minnesota. SUNY Downstate College of Medicine also suspended emergency room rotations for its medical students. 

Some teaching hospitals have banned medical students from emergency and intensive care units while allowing them elsewhere in their facilities. 

For medical students in the University of California system, clinical training continues for now, but they’ve been directed to avoid contact with suspected or confirmed COVID-19 patients, as have medical students across the nation. 

One Baltimore nursing student learned Friday that her psychiatric nursing rotation had been canceled for at least two weeks. She must complete more than 100 more clinical hours before graduation in May and has no idea whether her school, the University of Maryland, would be able to quickly find her a new placement. 

“I understand why they did it, for the precaution and the liability,” said the 26-year-old, who asked that her name not be used to protect her future career prospects. “But I had eight shifts scheduled in those two weeks. I’m in a kind of panic mode, worried I’m not going to finish in time for graduation.” 

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

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente. 

California Universities Work Together to Train More Nurse Practitioners to Fill Mental Health Care Gap

California Universities Work Together to Train More Nurse Practitioners to Fill Mental Health Care Gap

In an effort to address a shortage of mental health providers in the state of California, UC San Francisco (UCSF), in collaboration with UC Davis and UCLA, has announced the launch of an online training program for psychiatric-mental health nurse practitioners (PMHNPs). The program aims to train 300 new mental health providers to enter the state’s workforce by 2025.

An estimated 17 percent of Californians live with mental health needs, according to ucsf.edu. Many in that population lack access to mental health care and the problem is expected to worsen as the psychiatrist workforce continues to dwindle. Graduates of UC San Francisco’s new program are projected to serve as many as 378,000 patients over the next five years.

California currently has 13,000 nurse practitioners in its workforce, many of whom care for underserved populations in primary care settings including hospitals, prisons, schools, and other outpatient medical practices. PMHNPs are specialized mental health professionals authorized to prescribe psychotropic medications, treat severe mental illness and substance abuse disorders, and offer psychiatric care.

Program co-director Rosalind De Lisser, MS, RN, NP, associate professor in the UCSF School of Nursing, tells ucsf.edu, “I am tremendously excited about this innovative multi-campus program. It has the potential to expand our reach as an educational institution by providing excellent clinical training and contributing to the workforce development needs of California.”

Her sentiments were echoed by fellow co-director Deborah Johnson, DNP, RN, NP, also an associate professor in the UCSF School of Nursing, who stated: “Building upon our successful history as a top-ranked public PMHNP program, this program eliminates geographical barriers and allows California NPs in primary care to gain the education and training necessary to provide behavioral health services in their communities. The three-school collaboration provides high-quality educational resources for students across the state.”

The new program is scheduled to launch in fall 2020, with administrative offices located on the UC San Francisco campus. Students will be able to complete their clinical training component in the region where they live. The program aims to recruit 40 students for the first years and 65 students each following year, for a total of 300 PMHNPs over five years.

To learn more about the new online training program for psychiatric-mental health nurse practitioners being launched by UC San Francisco in collaboration with UC Davis and UCLA, visit here.

Border Flu Shot Protest: 4 Docs arrested

Border Flu Shot Protest: 4 Docs arrested

Four physicians and two others protesting their inability to vaccinate migrant detainees at the U.S. Customs and Border Protection (CBP) headquarters here were arrested last Tuesday for failing to comply with federal orders to disperse.

They were held for about an hour, according to some of those who were arrested.

The two groups of protesters — about 60 people in total — had gathered in two driveways leading to CBP headquarters for about an hour when one of the groups received a warning from federal officials that if they stayed in the driveway, they would be arrested, said Marie DeLuca, MD, an emergency room physician from New York who was one of those arrested. Some of the members had blocked the driveway by laying down across the road while others chanted, “No more death.”

“We stayed peacefully in the driveway entrances of their building and said that if they weren’t going to let us in to vaccinate against the flu, we were going to remain. They didn’t let us. Instead they chose to arrest members in one of the two groups,” DeLuca said.

She said her hands were secured behind her back with zip ties by officials from the Department of Homeland Security (DHS) as she and the other protesters were led into a conference room and told to wait. After about an hour following the protest, they were issued tickets with a court date for “failure to comply with the lawful direction of federal police officers or other authorized individuals,” and then released, she said.

A San Diego Union-Tribune reporter posted a video of some of those doctors being arrested.

At about 2 p.m. Tuesday, DHS’s press secretary tweeted a picture of the protesters and said, “Of course Border Patrol isn’t going to let a random group of radical political activists show up and start injecting people with drugs.”

Sen. Elizabeth Warren (D-Mass.) also tweeted a link to a video of the protesters, saying that “Children are dying in CBP custody due to the flu. Refusing to administer flu vaccines is neglectful and cruel.”

Other doctors arrested, who were part of the group Doctors For Camp Closure, included Mario Mendoza, MD, a former anesthesiologist who now lives in New York City and runs the organization Lifeundocumented.org; Hannah Janeway, MD, an emergency room physician in Los Angeles who helps run the Refugee Health Alliance; and Mathieu De Schutter, a pediatric hospitalist from San Luis Obispo, California. The non-physicians arrested were Rebecca Wollner of Jewish Action San Diego and Matthew Hom, a graduate student from Cerritos, California, who works with the group Never Again Action.

On Monday, the physicians began their three-day vigil and protest of federal immunization policies at the gate of the detention center in San Ysidro at about 11:30 a.m. They stayed until about 4:30 p.m. with no response despite repeated requests. Tuesday’s action took place nearby at the Chula Vista CBP headquarters.

DeLuca said the doctors and their supporters planned to return Wednesday to try one more time to administer the 120 influenza vaccines they brought with them for the detainees. They say it’s important for public health, not just to protect these detainees, but also everyone else they come in contact with.

Members of the groups chanted slogans and carried banners and signs calling on federal officials to let them administer the vaccinations to those inside. The vaccines were purchased with financial donations.

Originally published in MedPage Today.

Mass Shootings: How Docs and Nurses Heal

Mass Shootings: How Docs and Nurses Heal

Some healthcare professionals see blood, mangled bodies, and death every day, yet certain days are worse than others. As when, for instance, a dozen police officers are gunned down or 20 kids are killed in their elementary school in a mass shooting. Because public mass shootings happen nearly every 6 weeks in America, these tragedies are having a more frequent impact on the healthcare workforce.

Research data are sparse. One study surveyed 24 surgical residents working at Orlando Regional Medical Center in Florida in 2016. On June 12 that year, a gunman shot 49 people to death and wounded 53 others at the mass shooting at the Pulse nightclub. Three months later, rates of post-traumatic stress disorder (PTSD) and major depression were two and four times greater among the 10 residents on call that night versus the 14 off-duty residents. Though the differences didn’t reach statistical significance, assessments were revealing. A survey of the same residents 7 months after the mass shooting found that PTSD persisted in those affected in the on-call group but completely resolved in the off-call residents.

As part of an ongoing effort by MedPage Today to explore job stress and burnout among healthcare professionals, reporter Shannon Firth talked at length with physicians and nurses who shared personal experiences with mass shootings and how they affected their lives and careers.

Three Encounters With Mass Shootings

“After I Saw What I Saw, I Really Thought to Myself, ‘I Hope I’m Not Broken:'” Richard Kamin, MD (Sandy Hook school shooting, 2012)

“The Worst Night of My Professional Career:” Brian Williams, MD (Dallas police sniper attack, 2016)

“I Still Get That Pit Feeling in My Chest of, I Can’t Believe This is Happening:” Megan Duke, RN, CEN (San Bernardino terrorist attack, 2015)

MedPage Today intern Amanda D’Ambrosio assisted with reporting for these stories.

Originally published by MedPage Today.

UCLA Leads $25 Million NIH-Funded Study on Opioid Treatment in Rural America

UCLA Leads $25 Million NIH-Funded Study on Opioid Treatment in Rural America

Scientists from the UCLA Integrated Substance Abuse Programs have been selected to lead a $25 million study funded by the National Institutes of Health (NIH) to test treatments for opioid addiction in rural America.

A separate grant of $3.3 million from the NIH was awarded to another UCLA researcher from the substance abuse programs who will study the effectiveness of using text messages to help people with opioid addiction adhere to their treatment regimens.

The grants will be distributed over five years and are both part of the NIH’s Helping to End Addiction Long-term (HEAL) Initiative.

The first study will be led by Yih-Ing Hser, taking place at more than 40 primary care clinics in up to six states across the US. Hser is a distinguished research professor of psychiatry and biobehavioral sciences at the David Geffen School of Medicine at UCLA. The study will be specifically focused on rural regions because, according to the Centers for Disease Control and Prevention, the percentage of deaths from opioid overdoses is higher and there is typically less access to physicians than in urban areas.

Hser tells newsroom.ucla.edu, “We’ll build up the infrastructure to get the clinics ready to test the use of medication and behavioral therapies, so that we can conduct the study in as close to real-world settings as possible. A second phase of the study will look at the use of telemedicine to help overcome treatment barriers, such as the long travel time it sometimes takes to reach clinics in rural areas.”

The study’s co-lead investigator, Dr. Larissa Mooney, director of the UCLA Addiction Psychiatry Clinic at the Semel Institute, adds: “This study has the potential to expand access to life-saving treatments for opioid addiction in communities that have been significantly impacted by the opioid epidemic, and for new models of treatment to be sustainable even after the study is over.”

The second study on the effectiveness of using text messages to help people adhere to their treatment regimens will be led by Suzette Glasner, an associate professor-in-residence at the UCLA School of Nursing, and of psychiatry at the David Geffen School of Medicine at UCLA. Glasner’s research will assess whether using texts to deliver cognitive behavioral therapy will help patients stick to their opioid treatment medication regimens.

According to Glasner, “Medications for opioid use disorders are the gold standard treatment, and they continue to save and transform lives. But they only work if you take them, and adherence is low. My hope is that our work will help reverse this trend by providing a low-cost intervention.”

To learn more about the NIH-funded research of two UCLA Nursing studies on opioid treatment in rural America, visit here.

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