LA County Paramedics Told Not To Transport Some Patients With Low Chance Of Survival

https://www.npr.org/sections/coronavirus-live-updates/2021/01/05/953444637/l-a-paramedics-told-not-to-transport-some-patients-with-low-chance-of-survival?fbclid=IwAR1BM5NI_SDAuVmU4TqBUg1Hk0qmAWHroUN0b7jIzrbL053BZLgluBNeU1k

Paramedics in Southern California are being told to conserve oxygen and not to bring patients to the hospital who have little chance of survival as Los Angeles County grapples with a new wave of COVID-19 patients that is expected to get worse in the coming days.

The Los Angeles County Emergency Medical Services Agency issued a directive Monday that ambulance crews should administer supplemental oxygen only to patients whose oxygen saturation levels fall below 90%.

In a separate memo from the county’s EMS Agency, paramedic crews have been told not to transfer patients who experience cardiac arrest unless spontaneous circulation can be restored on the scene.

Both measures announced Monday, which were issued by the agency’s medical director, Dr. Marianne Gausche-Hill, were taken in an attempt to get ahead of an expected surge to come following the winter holidays.

Many hospitals in the region “have reached a point of crisis and are having to make very tough decisions about patient care,” Dr. Christina Ghaly, the LA County director of health services, said at a briefing Monday.

“The volume being seen in our hospitals still represents the cases that resulted from the Thanksgiving holiday,” she said.

“We do not believe that we are yet seeing the cases that stemmed from the Christmas holiday,” Ghaly added. “This, sadly, and the cases from the recent New Year’s holiday, is still before us, and hospitals across the region are doing everything they can to prepare.”

Speaking to the CBS affiliate in Los Angeles, Gausche-Hill said personnel would continue to do everything possible to save the lives of patients, both at the scene and in the hospital.

“We are not abandoning resuscitation,” she said. “We are absolutely doing best practice resuscitation and that is do it in the field, do it right away.”

“[We] are emphasizing the fact that transporting these patients arrested leads to very poor outcomes. We knew that already and we just don’t want to impact our hospitals,” she added.

Meanwhile, the state is looking for ways to increase its supply of oxygen for use in treating COVID-19 patients, Gov. Gavin Newsom said, according to the Los Angeles Times.

We’re just looking at the panoply of oxygen support … across the spectrum and looking how we can utilize more flexibility and broader distribution of these oxygen units all up and down the state, but particularly in these areas — San Joaquin Valley and Los Angeles, the larger Southern California region — that are in particular need and are under particular stress,” Newsom said.

Los Angeles County remains the worst-hit county in the U.S. for both confirmed COVID-19 cases and deaths from the disease. Johns Hopkins University listed more than 818,000 confirmed coronavirus cases and more than 10,700 deaths from complications from the virus in Los Angeles County by late Monday.

Last week, the new highly contagious coronavirus strain from the U.K. was discovered in Southern California. Experts have said it spreads faster than the common strain.

We Work on the Front Lines of COVID-19. Here’s What Hospitals Should Do

https://www.medpagetoday.com/infectiousdisease/covid19/86185?xid=fb_o&trw=no&fbclid=IwAR3iM5LMZj3BxWisk3puZ2T3bOCeBaDS_xCRoTrnVaZYfj4-DZPmUfr01cw

We Work on the Front Lines of COVID-19. Here's What Hospitals ...

A game plan from ground zero.

It’s only a matter of time before all of us are directly affected by COVID-19. Proper preparation is the only way to ensure high-quality patient care and staff well-being in this challenging time. Having collectively spent time caring for patients at two different tertiary care facilities in New York on the medical floors and intensive care units, common themes are emerging that represent opportunities for hospitals in other parts of the country to start taking action before COVID-19 patients start filling up beds en masse.

Staffing

It takes a LOT of people to care for a COVID-19 onslaught; mapping out different staffing scenarios in the event you have 40 or 400 COVID patients is imperative. Staffing needs for COVID patients are higher than normal because of the patients’ complex medical needs — many require ICU level nursing and respiratory therapists — and because both clinical and non-clinical staff will inevitably become sick and need to be taken out of work. Staff should be screened for symptoms and high-risk contacts; those who are symptomatic should be proactively encouraged to stay home instead of showing up to work not feeling well and putting other care team members and patients at risk. This requires back-up staffing plans to fill in when your people become sick. Shutting down non-urgent and elective departments provides staffing redundancy to pull from when needed. All employees should be given advance notice about staffing plans so that potential role changes are clear.

Testing

Robust testing processes for both patients and your healthcare workforce are critical for success. Hospitals should be taking this time to obtain in-house rapid testing kits to avoid unnecessary patient isolation and conserve personal protective equipment (PPE) while waiting for test results.

Healthcare workers are understandably scared about contracting COVID-19 themselves and giving it to their family members. We recommend all staff members be tested for active infection so that those who are infected can be proactively quarantined.

Forward-thinking institutions should be prioritizing antibody testing for healthcare workers. While this testing is still in its infancy, it is quite likely that those with strong antibodies to COVID-19 possess some degree of immunity. Therefore, if you can identify which doctors, nurses, respiratory therapists, physical therapists, and janitorial staff have already developed an immune response to COVID-19, these staff members can take priority staffing infected units with the goal of reducing the number of new infections in healthcare workers and limiting exposure to those who have yet to contract the virus.

Communication

Each institution’s COVID-19 protocols and policies change rapidly as we learn more about the virus. How you communicate these ever-changing procedures with staff is critical. Most hospitals rely on daily email updates that are text-heavy; however, overwhelmed inboxes and less time with devices while wearing PPE limits the success of email as a sole communication channel.

Communication through graphics takes on new importance — signage noting changes in hospital geography, large pictures of donning and doffing instructions, phone numbers to call with equipment shortages, and clear instructions to staff about testing protocols, isolation, and removing patients from isolation need to be conveniently placed where staff can access information in real time without consulting their electronic devices. High-yield locations for just-in-time visual communication include outside patient rooms, nursing stations, break rooms, and elevators, so that the target information reaches its busy, hard-working audience successfully and repeatedly, minimizing confusion and augmenting clarity.

Limiting the Need to Enter the Room

Given ongoing PPE shortages, particularly around single-use gowns and N95 masks, minimizing the number of instances that staff, particularly nurses, need to enter the room is critical. This requires an adjustment from normal patient care. We recommend extension tubing to bring IV poles and medications outside the room. Tablets such as iPads can permit video calls with patients to check on non-urgent items. Centralized monitoring of oxygen saturations for all admitted patients can minimize the frequency of supplemental oxygen adjustment.

Similarly, given the increased risk of COVID-19 in diabetic patients, continuous blood glucose monitoring can minimize the need for frequent manual fingerstick measurements for patients receiving supplemental insulin.

Discharge Planning

Discharging patients to home or rehabilitation facilities presents novel challenges. A home discharge requires education, equipment, and follow-up. Education on home monitoring of vitals signs like oxygen saturation and blood pressure with instructions on critical values that should prompt patients to return to the hospital can expedite discharge and open hospital beds for other sick patients. Both patients and family members must also be educated on quarantine procedures to limit household transmission.

Many patients will have temporary oxygen requirements and we have seen home oxygen shortages in our areas. Coordinating a strategy with your outpatient clinicians, home oxygen suppliers, and insurance companies can facilitate getting patients home sooner on home oxygen and freeing up beds for sicker patients. Further, many patients are eager to go home earlier since hospital visitation limitations mean they’re sitting in bed alone away from family and the more a hospital can do to safely discharge patients home with appropriate supplies and follow-up will be beneficial to both patients and the hospital.

Hospitals must also be prepared to integrate these patients into their existing telehealth infrastructure, which has become the mainstay of ambulatory medicine in lieu of traditional office visits. For many patients, this will be a new way of accessing care. Prior to discharge, hospital staff should ensure patients have downloaded the necessary apps with login information and feel comfortable they will be able to follow up with their physician using technology following discharge.

There is a huge opportunity for hospitals that have not been caring for large numbers of COVID-19 patients to prepare ahead of time in a manner that optimizes patient care and minimizes risks to staff. Those of us on the early front lines have learned many of these lessons the hard way. An ounce of prevention is worth a pound of cure — we encourage all healthcare systems to take action before the storm comes.