new-york-state-pause-executive-order?mod=article_inline; March 20, 2020,

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28 March 2020.

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March 2020.

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A state overview of COVID19 spread, interventions and preparedness

This is a trying time for the world battling the COVID-19 pandemic. By April 4th, 1,192,028 cases have been confirmed worldwide, with 64,316 deaths [1]. COVID-19 is now the 3rd leading cause of daily deaths behind heart disease and cancer [1-4]. The United States (US) holds the greatest number of confirmed cases [1]. By April 4th, 305,820 cases were confirmed with 8291 deaths and a fatality rate of 2.7% [1]. The US has a lower fatality rate than Italy (12.4%) and China (4.0%) [1]. The lower fa- tality rate could be partially explained by interventions taken by the government.

The current doubling time in the US for the SARS-CoV-2, virus, is 3 days [5]. However, the doubling time is currently 6 days for King County in Washington state [6]. In mid-March Washington state took measures to limit the spread of infection, by closing educational facili- ties, closing non-essential services, and a stay at home order (SAHO) [7,8]. These efforts have been associated with the percent increase in cases and fatalities decreasing (Fig. 2). According to the Institute for Dis- ease Modeling (IDM), the spread of infection into Seattle and Eastside

Number of Total Cases

decreased by about 90% and has continuously decreased since March 2^nd [9]. In late February, the reproductive number was about 2.7, whereas it was approximately 1.4 on March 18th [9].

Likewise, in California, with strict physical distancing measures in ef- fect in the Bay Area and Sacramento County, the doubling time is now 6 days [6]. On March 19th California closed non-essential services and educational facilities, and a SAHO was enacted [10] (Fig. 3). The percent increase in cases in California also decreased after this period (Fig. 2).

Additionally, a similar effect was observed after Idaho issued a SAHO and closed non-essential services on March 25th [11] (Fig. 3). After March 25th the fatality rate increased slightly, and then showed a de- creasing trend and lower percent increase in new cases (Fig. 2). The lack of testing does not appear to play a role in the decrease in fatality rate because the percentage of those testing positive continues to in- crease (Fig. 2).

Florida issued a SAHO on April 3rd, late in comparison to many other states [12,13] (Fig. 3.). However, their percent increase in cases over the past two weeks has decreased comparably to states in which a SAHO was in effect earlier (Fig. 2). This highlights the importance of other in- terventions. Florida mandated isolation orders of those at most risk, in- cluding senior citizens and those with underlying medical conditions [12]. Furthermore, travel was limited to that necessary to obtain or pro- vide essential services or to conduct essential activities, and businesses/ organizations were encouraged to provide delivery, carry-out or curb- side service [12].

New York holds the greatest number of cases and deaths (Fig. 1) [1]. This forced the state to consider extraordinary measures aimed at in- creasing hospital capacity and decreasing density of cases. To address the first issue, an executive order was issued, allowing the state to in- crease hospital capacity [14]. In addition, there was deployment of a 1000-bed hospital ship to New York Harbor [15]. Moreover, an execu- tive order signed on March 19th mandated all businesses requiring in- office personnel to decrease their in-office workforce by 75% [16] (Fig. 3). Another executive order on March 20th, enforced the closure of all non-essential businesses [17] (Fig. 3). The percent increase in cases dropped after these interventions (Fig. 2).

The relative increase in cases appears to be abating, but the fatality rate is increasing (Fig. 2). These trends may suggest that there are inad- equate healthcare capacity and medical supplies [18]. In response, the Centers for Medicare & Medicaid Services (CMS) granted changes to provide some flexibility for hospitals, physicians and healthcare organi- zations [19]. CMS allowed hospitals to provide services for patients

Fig. 1. Total cases of COVID-19 and total deaths due to COVID-19 in 5 states. The total cases and total deaths plotted as a function of time for Washington State (WA), California (CA), New York (NY), Florida (FL) and Idaho (ID). As of April 1, 2020, the total number of cases in descending order is NY N CA N FL N WA N ID. The total number of deaths in descending order is NY N WA N CA N FL N ID.

Total Cases of COVID-19 and Total Deaths due to COVID-19 in 5 States

120,000

110,000

100,000

90,000

80,000

70,000

60,000

50,000

40,000

30,000

20,000

10,000

0

4,000.00

3,000.00

2,000.00

1,000.00

0.00

15-Mar 17-Mar 19-Mar 21-Mar 23-Mar 25-Mar 27-Mar 29-Mar 31-Mar 2-Apr 4-Apr

Date

WA Total Cases CA Total Cases NY Total Cases FL Total Cases ID Total Cases WA Total Deaths CA Total Deaths NY Total Deaths FL Total Deaths ID Total Deaths

transferred outside of their building [19]. The new rules allow for pa- tient transfers to ambulatory surgery centers, freeing Hospital beds for the critically ill [19]. Many states are still projected to have shortages in hospital and ICU beds and ventilators (Fig. 4) [18,20].

Of the 5 selected states, Washington and Florida are projected to have a shortage of ICU beds; Idaho and New York are projected to have a shortage of hospital and ICU beds, and all 5 states are projected to have a shortage of ventilators (Fig. 4) [18,20]. There is a national stockpile of ventilators that can be deployed [21,23], but may be insufficient to supply all of the hospitals’ needs [18,20,22].

There is an association between implementing social distancing and a lowering of the percent increase of cases. Some states implemented interventions earlier than others did, which may be responsible for the differing fatality rates. Encouraging states to implement more wide- spread distancing interventions at an earlier time has the potential to act on multiple levels in preventing the spread of COVID-19, and could make all the difference in preserving thousands if not hundreds of

thousands of lives in the United States. Now is not the time to return to normalcy; we can win this fight together.

Brendon Sen-Crowe Adel Elkbuli MD, MPH*

Department of Surgery, Division of Trauma and Surgical Critical Care,

Kendall Regional Medical Center, Miami, FL, USA

*Corresponding author at: 11750 Bird Road, Miami, FL 33175, USA.

E-mail address: [email protected].

Mark McKenney MD, MBA

Dessy Boneva MD

Department of Surgery, Division of Trauma and Surgical Critical Care,

Kendall Regional Medical Center, Miami, FL, USA University of South Florida, Tampa, FL, USA

24 March 2020

https://doi.org/10.1016/j.ajem.2020.04.020

Percentage (%)

Percentage (%)

Percentage (%)

Percentage (%)

Fig. 2. Fatality rate, percent increase in cases and percentage of individuals who tested positive for COVID-19 across 5 states. The fatality rate (blue), percent increase in COVID-19 cases (orange) and Percentage of those who tested positive (gray) reported in each state. a. New York; b. Washington State; c. Idaho; d. California; e. Florida.

California

Washington

160.

160.

120.

120.

80.

80.

40.

40.

0.

0.

15-Mar 18-Mar 21-Mar 24-Mar 27-Mar 30-Mar 2-Apr 5-Apr

15-Mar 17-Mar 19-Mar 21-Mar 23-Mar 25-Mar 27-Mar 29-Mar 31-Mar 2-Apr 4-Apr

Percent Fatality

Percent Increase in Cases

New York

Percent Tested Positive

Percent Fatality Percent Increase in Cases Percent Tested Positive

Florida

160. 160.

120.

120.

80.

80.

40.

40.

0.

15-Mar 17-Mar 19-Mar 21-Mar 23-Mar 25-Mar 27-Mar 29-Mar 31-Mar 2-Apr 4-Apr

0.

15-Mar 17-Mar 19-Mar 21-Mar 23-Mar 25-Mar 27-Mar 29-Mar 31-Mar 2-Apr 4-Apr

Percent Fatality Percent Increase in Cases Percent Tested Positive

Percent Fatality Percent Increase in Cases Percent Tested Positive

Idaho

200.

160.

120.

80.

40.

0.

15-Mar 17-Mar 19-Mar 21-Mar 23-Mar 25-Mar 27-Mar 29-Mar 31-Mar 2-Apr 4-Apr

Percent Fatality Percent IncrDeaasteeof Cases Percent Tested Positive

Percentage (%)

April 2020

March 2020

February 2020

January 2020

1/21: First Case

2/29: Declared State of Emergency

3/13: Closure of Educational Facilities

3/25: Closure of Non- essential Services

WA

3/23: Stay at Home Order

NY

3/22: Stay at Home Order

3/04: First Case

3/18: Closure of Educational Facilities

3/07: Declared State of Emergency

3/20:

1. Closure of Non- essential Services
2. Stay at Home Order

CA

1/26: First Case

3/19:

1. Closure of Non-essential Services
2. Stay at Home Order
3. Closure of Educational Facilities

3/04: Declared State of Emergency

3/13:

1. First Case
2. Declared State of Emergency

3/23: Closure of Educational Facilities

ID

3/25:

1. Stay at Home Order
2. Closure of Non-essential

3/09:

Declared State of Emergency

4/03: Stay at Home Order

3/17: Closure of Educational Facilities

3/01: First Case

FL

Fig. 3. Timeline of major interventions in 5 states. The relative time points of major interventions implemented by Washington State (WA), California (CA), New York (NY), Idaho (ID) and Florida (FL).

ICU Beds

Hospital Beds Needed

Ventilators Needed

Available Hospital Beds

ICU Beds Needed

Florida

Idaho

New York

California

Washington

Hospital Beds Available ICU Beds

0.00

20,000.00

40,000.00

60,000.00

80,000.00

Hospital resources

Fig. 4. Hospital resources and projected need across 5 states. The total number of hospital beds in the State (Blue), the number of available hospital beds (Orange), projected number of hospital beds needed (Gray), total number of ICU beds (Yellow), the number of available ICU Beds (Light Blue), projected number of ICU beds needed (Green), and projected number of ventilators needed (Purple) were reported in Washington state, California, New York, Idaho, and Florida. Washington and Florida are projected to have a shortage of ICU beds; Idaho and New York are projected to have a shortage of hospital and ICU beds, and all 5 states are projected to have a shortage of ventilators.

References

1. COVID-19 map. Johns Hopkins Coronavirus Resource Centerhttps://coronavirus.jhu. edu/map.html; January 22, 2020, Accessed date: 3 April 2020.
2. Lung cancer facts: 29 statistics and facts: LCFA. Lung Cancer Foundation of Americahttps://lcfamerica.org/lung-cancer-info/lung-cancer-facts/, Accessed date: 3 April 2020.
3. Heart disease facts. Centers for Disease Control and Preventionhttps://www. cdc.gov/heartdisease/facts.htm; December 2, 2019, Accessed date: 3 April

2020.

1. Interim guidance for coronavirus disease 2019 (COVID-19). Centers for Disease Con- trol and Preventionhttps://www.cdc.gov/coronavirus/2019-ncov/community/large- events/mass-gatherings-ready-for-covid-19.html; March 15, 2020, Accessed date:

3 April 2020.

1. Soucheray S. US COVID-19 cases surge past 82,000, highest total in world. Center for Infectious Disease Research and Policyhttp://www.cidrap.umn.edu/news- perspective/2020/03/us-covid-19-cases-surge-past-82000-highest-total-world; March 26, 2020, Accessed date: 3 April 2020.
2. Reported COVID-19 cases over time. https://coviz.us/?counties=%22San% 20Francisco,%20California|Los%20Angeles,%20California|Broward,%20Florida| Kenton,%20Kentucky|Chenango,%20New%20York|Anoka,%20Minnesota| Cameron,%20Texas|Porter,%20Indiana|Miami-Dade,%20Florida%22.
3. Proclamation by the governor amending proclamation 20-05. Office of the Governorhttps://www.governor.wa.gov/sites/default/files/proclamations/20- 25%20Coronovirus%20Stay%20Safe-Stay%20Healthy%20%28tmp%29%20% 28002%29.pdf; March 23, 2020, Accessed date: 3 April 2020.
4. Burstein R, Hu H, Thakkar N, Schroeder A, Famulare M, Klein D. Understanding the impact of COVID-19 Policy change in the greater Seattle area using mobility data. In- stitute for Disease Modelinghttps://covid.idmod.org/data/Understanding_impact_ of_COVID_policy_change_Seattle.pdf.
5. Thakkar N, Burstein R, Hu H, Selvaraj P, Klein D. Social distancing and mobility re- ductions have reduced COVID-19 transmission in King County, WA. Institute for Dis- ease Modelinghttps://covid.idmod.org/data/Social_distancing_mobility_reductions_ reduced_COVID_Seattle.pdf#/.
6. Executive order N-41-20. Executive Department – State of Californiahttps://www. gov.ca.gov/wp-content/uploads/2020/04/4.1.20-EO-N-41-20.pdf; March 19, 2020.
7. Proclamation. The Office of the Governor. https://coronavirus.idaho.gov/wp- content/uploads/sites/127/2020/03/proclamation_extreme-emergency- declaration_032520.pdf; March 25, 2020.
8. Executive Order Number 20-91. Office of the Governor. https://www.flgov.com/wp- content/uploads/orders/2020/EO_20-91.pdf; April 01, 2020.
9. Department of Health announces two presumptive positive COVID-19 cases in Flor- ida. Department of Health Announces Two Presumptive Positive COVID-19 Cases in Florida | Florida Department of Healthhttp://www.floridahealth.gov/newsroom/ 2020/03/030120-two-presumptive-positive-covid19-cases.pr.html; March 1, 2020,

Accessed date: 3 April 2020.

1. During coronavirus briefing, Governor Cuomo issues executive order allowing state to increase hospital capacity. Governor Andrew M. Cuomohttps://www.governor.ny.gov/news/during-coronavirus-briefing- governor-cuomo-issues-executive-order-allowing-state-increase; March 16,

2020, Accessed date: 3 April 2020.

1. Amid ongoing COVID-19 pandemic, Governor Cuomo announces deployment of 1,000-bed hospital ship ‘USNS comfort’ to New York Harbor. Governor Andrew M. Cuomohttps://www.governor.ny.gov/news/amid-ongoing-covid-19-pandemic- governor-cuomo-announces-deployment-1000-bed-hospital-ship-usns; March 18,

2020, Accessed date: 3 April 2020.

1. Governor Cuomo signs executive order mandating businesses that require in-office personnel to decrease in-office workforce by 75 percent. Governor Andrew M. Cuomohttps://www.governor.ny.gov/news/governor-cuomo-signs-executive- order-mandating-businesses-require-office-personnel-decrease; March 19, 2020,

Accessed date: 3 April 2020.

1. Governor Cuomo signs the ‘New York State on PAUSE’ executive order. Governor Andrew M. Cuomohttps://www.governor.ny.gov/news/governor-cuomo-signs- new-york-state-pause-executive-order; March 20, 2020, Accessed date: 3 April

2020.

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2. Trump administration makes sweeping regulatory changes to help U.S. healthcare system address COVID-19 patient surge. Centers for Medicare & Medicaid Serviceshttps://www.cms.gov/newsroom/press-releases/trump-administration- makes-sweeping-regulatory-changes-help-us-healthcare-system-address-covid- 19; March 30, 2020, Accessed date: 3 April 2020.
3. COVID-19 hospital capacity estimates. Harvard Global Health Institutehttps:// globalepidemics.org/; 2020, Accessed date: 3 April 2020.
4. US Department of Health and Human Services. Assistant secretary for preparedness and response. Last reviewed, Strategic National Stockpile; November 18, 2019. https://www.phe.gov/about/sns/Pages/default.aspx.
5. Administrator for the centers for medicare and medicaid services and member of White House Coronavirus Task Force Seema Verma interviewed on U.S. prepared- ness for ongoing coronavirus pandemic. CNN; March 13, 2020. http://edition.cnn. com/TRANSCRIPTS/2003/13/nday.05.html.
6. COVID-19 Map. ArcGIS. https://csbs.maps.arcgis.com/apps/Media/index. html?appid=3f9e4596d4a44cb1b69b71c9cf87ec78, Accessed date: 3 April 2020.

Leveraging existing quality improvement communication strategies during the COVID-19 crisis

1. Background

Responding to the 2019 Coronavirus pandemic has been an unex- pected and unprecedented challenge for Emergency Medicine leaders and frontline clinical staff. At our university-affiliated, tertiary care emer- gency department (ED) in Boston, departmental, hospital, and health sys- tem leadership has provided extensive communication and training surrounding operational changes, including personal protective equip- ment (PPE) management, COVID-19 testing policies, potential role reassignments, occupational health policies, and others. However, as case numbers began to grow it became clear that frontline clinicians and staff also required guidance regarding the management of COVID-19. Given the rapidly-changing data surrounding typical symptom presentations, affected demographics, therapeutics, and ED man- agement strategies for COVID-19, our ED Quality and Safety leader- ship identified the need for a rapid and reliable method to disseminate the latest insights and recommendations. We there- fore launched a twice-weekly, video-based ED COVID Case Confer- ence (ED CCC) on March 18, 2020, with the following goals: (1) to facilitate discussion regarding ED management and disposition de- cisions; (2) to provide updates on current clinical recommenda- tions; (3) to disseminate information related to current

departmental and hospital case trends.

1. Methods

Given the need to identify and operationalize a clinical manage- ment communication tool as rapidly as possible, Q&S leadership looked to existing methods of case review and dissemination of clinical learning for guidance. Like many others, our department has a monthly Morbidity and Mortality conference which focuses on cases that represent opportunities for system or individual clini- cian practice learning. These have traditionally been prepared and presented by a senior resident. We adapted this format for the ED CCC with the following key differences: to streamline the review and presentation process, cases were identified and moderated by an attending physician member of the Q&S leadership; case slides were initially prepared by a nurse member of the Q&S leadership; cases were selected to facilitate discussion surrounding diagnosis and management, regardless of improvement opportunities; to allow for rapid dissemination of information, the ED CCC is planned to be held up to twice weekly until the end of the acute phase of the COVID-19 crisis.

The first ED CCC, hosted securely on a password-protected enter- prise Zoom(R) platform, was held for only the ED faculty (including at- tending physicians and a pharmacist), in order to obtain feedback and make iterative improvements to the format. Subsequently, all ED clini- cal staff – including staff nurses, resident physicians, advanced practice providers (APP), pharmacists, and Respiratory therapists – were invited to attend. Given the large number of attendees, expert discussants were identified from key role groups (critical care attending physician, senior resident, chief APP, pharmacist, clinical nurse specialist) to reduce chat- ter throughout the video conference. Other attendees were encouraged to utilize Zoom(R)’s chat function to relay questions and comments, which were compiled by a member of the ED Q&S administrative lead- ership staff, researched, and reported back with answers during the fol- lowing conference.

Each one-hour conference includes the following elements, allowing for discussion during each case: