You’re listening to a press conference from the Harvard T.H. Chan School of Public Health with Dr. Paul Biddinger, vice chair for emergency preparedness in the Department of Emergency Medicine at Massachusetts General Hospital and medical director for emergency preparedness at the hospital and at Partners Healthcare. This call was recorded at 11:30 am Eastern Time on Thursday, April 9.
Previous press conferences are linked at the bottom of this transcript.
PAUL BIDDINGER: Nice to get to speak with everybody. I bring my remarks sort of from the framework of certainly my work at the Harvard School of Public Health, but also as an emergency physician at Mass General and someone responsible for the emergency planning efforts for my hospital and for my health care system.
I think, just to give everybody sort of a bit of an overview of where we think we are here in the Boston and northeastern region in the United States, we certainly are still on the ascending portion of the curve. We are seeing increasing numbers of patients for sure at my hospital. We have about 110 patients with COVID in the intensive care unit, and about 220 to 230 patients with COVID overall in the hospital right now.
That means that about 40% of the patients with COVID that require hospitalization are in our intensive care unit. We believe, based on our modeling that we are between one to two weeks from potentially the peak of hospitalizations, both for critical illness and general illness.
We believe that roughly in a week, give or take, obviously, several days, that we think we may hit the peak of hospitalizations and the peak of critical care illness is delayed by a few days beyond that, just because patients typically take a couple of days to get to the critical level of illness in their course of being infected with COVID.
We had been planning a lot based on our modeling. We have healthcare systems engineers that model with us. We’ve been looking at data from China, from South Korea, from many places in the world. And I would say notably from Italy, where we’ve had access to a great deal of data. And we’ve been comparing our experience at Mass General and its Partners Healthcare with both the northern Italian and in central Italian experience to try and see what might be ahead of us.
I’m very pleased to say that for now, about a week or so, data no longer looks as much like it did as a northern Italian situation. So, northern Italy, as everyone is well aware, was very severely affected by COVID, still is severely affected by COVID, and there was a period where our hospital admissions data looked very much like northern Italy.
Roughly about a week to two after the implementation and then strengthening of social distancing, physical distancing instructions from the governor and from multiple mayor’s here in eastern Massachusetts, we now have seen that our curve of arriving patients, both with general illness and critical illness, has decreased. And we are very pleased to say that it looks like the peak numbers for critical illness are less than they had previously been.
Mass General Hospital is a large hospital. We have about 1000 beds, overall, we have about 150 critical care beds on an average, on a daily basis. And on average, 47 patients within those 150 ICU beds are typically on ventilators.
So, as you can tell by the fact that currently we have more than 100 COVID patients on ventilators right, now we have more than double the number of patients on ventilators currently with COVID than we would normally have in total on patients on ventilators in a normal situation.
We have created three different intensive care unit spaces outside of our normal existing intensive care units in order to be able to respond to the needs of our patients. And we have the capacity here to surge up to 300 critical care beds if needed. So again, normally we have 150 and we can surge up to 300.
We expect that we will probably need to take care of more than 200 patients with ICU needs with critical care illness, including, you know, many of our existing ICU spaces but newly created ICU spaces in general medical wards, as well as in our post anesthesia care unit, our recovery area in order to meet the demands of the surge.
We are using all of the traditional ventilators we have and will likely need to incorporate transport ventilators, as well as anesthesia machines, in order to provide ventilation for all the patients at the peak of illness.
We are already using some anesthesia machines now as ventilators in our post anesthesia care unit, our recovery area. We are cautiously optimistic that, with the numbers we think we are anticipating, that we will have enough ventilators, and we will have enough intensive care unit spaces, but we certainly are anticipating – we have been working to talk about how we would institute crisis standards of care if they were needed.
So, as most all of you know the governor here in Massachusetts just released a crisis standards of care guidance for hospitals in Massachusetts. And I would say there were times when we were more on the northern Italian situation that we thought this would be an impending need. We’re very grateful that right now, the numbers do not suggest that we will run out of resources in the way that the previous modeling had suggested.
But we nonetheless believe that it’s extremely important as part of responsible emergency planning to anticipate how we would ethically, fairly, transparently, scientifically make decisions across lots of different hospitals, including our own hospitals, if we ever did not have sufficient numbers of ventilators or ICU spaces or others.
And so, we are very grateful for the leadership of the state in this regard. And for anyone who’s read those crisis standards of care documents that there – it’s not simply a list of steps that one should take to determine whether or not someone is able to be triaged to receive critical care resources, but it actually requires systems and structures, including triage officers and triage committees, within a hospital.
And so, we have within our hospital done work to make sure we communicate with people who would be affected if there were to be crisis standards of care.
But again, I really would emphasize that right now that’s not what we think we need to do. And everything about our response over the last three months has been focused on maximizing resource availability, so that we can take care of all the patients who need us.
And so, I think I will probably stop there and see what questions you all have, but hopefully that gives a sense for where we are.
We have done an extraordinary amount of work. Hundreds and hundreds and hundreds of people have done yeoman’s work to open up new ICU spaces, to move ventilators around, to come up with contingency plans, to work exceptionally hard, and I’m indebted to all of them for the work that they’ve done to help us be in a position we are in, and though we have many, many, many weeks still of hard work ahead of us, we are certainly ready to continue to provide care throughout this outbreak.
MODERATOR: Alright, looks like the first question.
Q: Hi, thanks very much for doing this. I have a question more focused on, I guess, sort of the research side as opposed to the clinical care at MGH. So, as the effects of the outbreak start being seen in smaller towns and rural communities, what are some of the things that you look to, I guess, to judge how prepared these smaller communities are? You know, what are some of the factors that will leave some may be better prepared than others?
PAUL BIDDINGER: It’s a great question. I think there are both systemic factors and medical factors that go into this.
I think systemic factors are how well communities can come together to aggregate resources and monitor and manage their capacity. Just recently, we have stood up a citywide capacity management group among the Boston hospitals. And obviously, you know, in the Boston area we’re obviously fortunate to have a large amount of medical resources, but still just the way patients present, one hospital can become more severely overloaded with critical illness than another one or inpatients, etc.
And so, we’ve really come together to, on a daily basis, share capacity data and make sure that patients arrive at or can be transferred to places with sufficient capacity to take care of them.
I think, as more rural areas get hit, clearly, they will need to do the same. They face different challenges, certainly, with long transport times for ambulances, as well as, generally speaking, fewer ambulance resources to move patients around.
But they need to create communities where they’re able to identify where there is still hospital capacity and create structures to move patients around in ways that they probably don’t on a normal basis.
And then on the clinical side, you know, part of what I think is helping us so much is that from Italy, from China, from other places in the world, that the data about how to best take care of patients with this extraordinary illness is moving fast.
COVID causes a lot of unusual complications that we haven’t really seen before in different infectious diseases, such as a significantly prothrombotic state. That means people clot much more easily and there have been a lot of complications with people making clots. So, the data on how best to manage anticoagulation is being shared in real time.
There’s a fair amount of kidney damage that is occurring, sometimes related to the fluid management of the patients, sometimes related to the disease. And so again we’re trying to share protocols on how best to manage the fluid status as well as the respiratory status of these patients. And so, our hospital is sharing its resources quite quickly and quite broadly with others, based on the lessons that we are able to learn from those who are gracious enough to share their lessons with us.
And so certainly as you get into more rural communities where their intensive care unit expertise and staffing is more thinly stretched, hopefully, they can build on the resources from either those who have already experienced the outbreak earlier or larger institutions that can share resources.
Last thing I’ll say is we’re certainly all trying to pursue telemedical strategies so that, again, in these more rural areas where they may not have quite the same access to intensivists, working with some of the national societies, such as the Society for Critical Care Medicine or American Thoracic Society or others to try and create telemedicine medical strategies to especially give them critical care expertise is an important need that I know several people are trying to work on.
MODERATOR: Alright, next question.
Q: Thank you and thank you, Paul, for doing this. Governor Baker repeatedly refers to a surge, which is a little bit confusing. I mean, are we in the surge now, as far as you see it, or is that still something that’s coming? And assuming that it’s kind of a typical bell curve, how long do you expect the plateau to last? And just one other piece of this question. Can you at all quantify if we had been like northern Italy, what would be the totals we would have been seeing compared to what you expect us to see now? Thank you.
PAUL BIDDINGER: Yeah, so, I think a couple thoughts, you know. In my world, surge in some sense is a term of art in the emergency management world. And so, we’re absolutely in the surge.
It’s a way we aggregate the S’s of surge planning – so, staff, stuff, space, and the system – because we need personnel, we need resources, we need either head walls or hospital care spaces, and we need a system that brings it all together. So, anything that increases or changes the way we deliver medical care to respond to the disaster is part of surge planning.
We’re definitely in the surge and, you know, again, we estimate based on at least our own internal modeling, we’re a week or two away from the peak and, you know, if you consider that maybe probably the second week of March is when we started up the surge, it is a bit of a bell curve. The tail is a little long. So, it’s not a perfectly distributed bell curve because unfortunately there are prolonged hospitalizations, especially in the ICU for this.
But, you know, it’s fair to assume that, you know, ramping down on the other side of the curve will be six to eight plus weeks. What none of us knows is whether when there will be a second wave, you know, how the need to reopen society to take care of some of the other important economic considerations that are certainly very relevant, will affect what continuing COVID infection may look like.
So, lots of people are working really hard on that. I think you know the plateau is probably a week to two of staying somewhat level, but again probably – we all want it to go away as fast as it can possibly go away but I think six to eight weeks is realistic.
Q: Thank you. And the Italy question?
PAUL BIDDINGER: I’m so sorry. So, the Italy question. You know, again, all of these are models. They’re not predictions or estimates, but the model had suggested that, say for Mass General as one example, we really may have needed every one of those 300 critical care beds that we can possibly create or just a little bit above. I would say, looking across Partners Healthcare system, the modeling suggests that a full saturation of everything we could possibly do, but, thankfully didn’t exceed it by, say, two or three times.
Obviously, that’s different for every hospital, different in every region, but I think it made us nervous, but cautiously thinking that, you know, with maximum resource mobilization, we would be able to respond to the peak. I’m extremely grateful that we don’t think we’re going to hit that peak.
MODERATOR: Next question.
Q: Hi, Paul. Thanks. Thanks for doing this. I wanted to shift the focus to health care workers. And I wonder if you could talk about, first of all, how the disease has been impacting your staff. And second, what is life like in the ER these days?
PAUL BIDDINGER: I think, you know, the impact on staff is obviously varied. I think lots of people process this and experience this differently. I think everybody’s tired. I think everybody is at least a little anxious, though maybe somewhat less so.
I think the longer we go in this without seeing a major increase in rates of healthcare worker infection, the more reassurance we have that our personal protective equipment is safe, that our policies, our procedures are safe. You know, we look at this in my health care system every single day. We look at it extremely closely, and we continue, thankfully, to not see any signals that would suggest that there are excess health care worker infections due to problems with PPE.
I think there’s been extraordinary outpouring of support. You go up to any one of our units, they have signs written in crayon by kids that have been sent into the hospital. They have notes, cards of well wishes. It’s really extraordinary and, I hope this doesn’t sound a little too saccharin, but as much as I love walking around the hospital normally, walking around right now, you can really feel the mission. It’s just extraordinary to see.
The nurses, the clinical staff, the physicians, especially in these floors that have been turned into ICU spaces, you know, you might think that it might seem like people are overwhelmed or scared and it’s exactly the opposite. It’s extraordinary that they feel almost – I think a lot of people do feel proud to be able to take care of patients during this time.
Again, there’s still a lot of weeks ahead of us and I think people are tired. We’re worried about how fatigued and how stressed people can be, but we’re doing our very best to rotate staff and to try and give them resources and ways to step back and destress whenever possible.
Q: Do you have numbers of people who are out ill? And I know that MGH has more stringent, you know, any symptoms whatsoever stay home policies and has that sort of lent to an increase in the demands on those who do go to work?
PAUL BIDDINGER: It does, no question. So we absolutely, of course, for the, you know, safety of the workplace, insist that everyone any symptom go home and contact occupational health. We, in fact, have created an app so that everyone across Partners Healthcare coming into work every single day has to fill out a brief attestation that they don’t have fever, sore throat, cough, muscle aches, fatigue.
And they have to do that every single day and it shows a little picture on their smartphone or they fill out a form if they don’t have a smartphone, so that we have a record of it and it’s just to enforce how important it is that people who have symptoms that they tell us if they have symptoms.
And then, of course, we test people if they have symptoms. More than 90% of our workforce that report symptoms do not have COVID and so thankfully it’s a small number. And it’s actually a smaller fraction of our workforce that test positive than the overall number of people who test positive in the Commonwealth, which is one of those reassuring data points that we that we monitor so closely.
But it does create staffing challenges. As soon as someone is sent home, of course, they can’t work for the day and it usually takes us at least 24 to 48 hours to get the testing results back and that means that there’s a hole in the schedule. And so, across the entire hospital staffing has been a very significant challenge.
We’ve been redeploying staff, moving a lot of staff around to be able to meet the needs. But, the staff furloughs are really sort of unavoidable, and again, certainly nothing we could change in order to bring people back if we’re if we’re going to threaten safety.
Q: Very good. Thank you very much.
MODERATOR: Next question.
Q: Good morning. So, I just wanted to ask about the decontamination system that is going to be up and running soon in Somerville. Do you know when it will be actually starting and how important is it to have the system for the frontline workers and medical personnel so that you don’t have repeatable zones where the personnel are using these masks that are contaminated because of just the extreme shortage?
PAUL BIDDINGER: Yeah, so obviously the Battelle system that is being rolled out is just extremely helpful to us to be able to help preserve our supply of personal protective equipment.
We are doing test runs now. We hope that over the weekend, early into next week, we’re going to be able to start decontaminating N-95 at an increasing rate.
Obviously, we need to make sure that all of our indicators, all of our tests, prove that the process is working exactly as it’s supposed to and that what are called indicators, the bacterial and viral indicators, others are all effective.
It absolutely helps preserve our PPPE, our personal protective equipment supply. I would say with respect to the extended use or reuse policies, what we’ve been doing conforms exactly to what CDC recommends. And one important distinction that, just to make make clear – I don’t know whether it was something in your comment or not – but we do not permit reuse of any N-95 or personal protective equipment used in an aerosol generating procedure for a COVID patient. So, anywhere where we think there’s been COVID contamination of the PPE is not allowed to be reused because that again wouldn’t actually meet CDC criteria that we don’t believe as safe.
Q: Us being in the surge right now, how important is it to have this kind of system available to hospitals like MGH?
PAUL BIDDINGER: It’s extremely important. I think we would not likely be able to sustain our current N-95 usage and strategy without it. You know, we have absolutely been doing everything we can to acquire new product, to purchase N-95 wherever we can find them.
But of course, everyone across the country and really around the world is trying to do the same thing. So, this gives us a boost of maybe, we won’t know until we’re up and running for sure, but say 20 to 30% boost in our N-95 options.
And so, as we get it up and running across Partners, it’s certainly our hope to allow us to work with other hospitals to give them the same resources as much as possible. You know, this is important for the whole healthcare community. And so, we hope that will get up to 80,000 respirators per day that can be decontaminated.
That’s much bigger than the need we have across Partners and so, again, we want to share that. We want to work with others in the healthcare space so that, you know, we can support all healthcare worker safety as much as we possibly can.
Q: So right now, it’s for the Partners Healthcare network hospitals?
PAUL BIDDINGER: We’re going through a phased start right now. So right now, it’s actually just a small subset of N-95, not even just all across Partners, just as I said. We have to make sure it works. We have to make sure that the throughput is effective.
But the hope is to expand and again we’ll be communicating with partners in the Mass Hospital Association, with others, with state government, to make sure that again we can do the very most we can with the capability for that.
Q: Thank you.
MODERATOR: Next question.
Q: Hi. Thank you for taking my question.
PAUL BIDDINGER: Absolutely.
Q: Appreciate it. So, I wonder if you’ve – I know this is not really your area of expertise – but have you heard anything about the possible use of the TB vaccine and whether you think that’s viable? And also, what kind of impact of vaccine in general would have on the burden on hospitals and treating COVID-19?
PAUL BIDDINGER: So, I can’t comment on the TB vaccine specifically. On a vaccine in general, obviously, you know, vaccines are game changers in terms of disease transmission. You know, we’ve seen this in so many areas with diseases that went away for the most part when we had effective vaccines and, unfortunately, diseases that have resurged when we’ve had differences in how much vaccines are used.
I think it’s just hard to predict right now whether and when there might be an effective vaccine. But if there is one, and if it can be produced to a large scale, and then, of course, administered on a large scale, that would just be absolutely enormous.
We’re all hopeful that we can find a safe and effective vaccine as quickly as possible. And then when we do that, we can manufacture it and distributed as quickly as possible on a very large scale.
Q: Thank you.
MODERATOR: Okay, it looks like another question.
Q: Hi, just a quick follow up. You tallied the of the number of ventilators MGH has at its disposal. Are any of the have any of those been sent? You know, we hear about the federal government sending stuff here and there. Have any of these been sent or borrowed, or are these things that were within your stock or that were acquired by MGH, you know, through its regular purchasing arrangements?
PAUL BIDDINGER: So, for Mass General all of the ventilators that we have our ventilators that we either owned or ordered as we were heading into this outbreak. Across Partners Healthcare, we tried to purchase more than 200 ventilators and we were able to acquire I think about 60 of those and basically, right now, we don’t believe we’re going to be receiving any additional ventilators from our orders anytime soon.
We have not received any ventilators from the Strategic National Stockpile but other hospitals within Partners Healthcare have received ventilators, as they have surged with COVID patients.
Q: Thank you.
Q: A little bit more about the city-wide capacity management group. How is that working in our hospitals, actually going across systems and giving stuff that other hospitals need, and who’s running it?
PAUL BIDDINGER: So, it is a voluntary association of all of the hospitals in the Boston area and it is being co-led by critical care physicians from Mass General and Partners and from Beth Israel.
And again, all of the hospitals are welcome to participate and they voluntarily share data on their ICU capacity, on the numbers of patients that are hospitalized.
And they talk about where there are areas – where there’s opportunity for more patient flow. So, again, the different hospitals in the area have different numbers of either ICU patients or ICU capacity, and for the most part, really, the group tries to help direct the patients or help identify areas where patients can go, as opposed to move staff or other physical resources around.
And so, there’s been a couple of cases so far, where different hospitals have hit capacity and have been unable to care for additional critical care patients and hospitals have stepped up and volunteered to accept either transfers or emergency department admissions.
And so, it’s really a fantastic way that people are not trying to follow some of the normal transfer guidelines, but really make sure that – the transfer patterns, I should say – but make sure that you know patients end up in the right critical care space whenever possible.
So, it’s a really nice example of everyone sort of dropping their typical affiliations and just making sure that we make capacity for the patients who need hospitalization.
Q: Yeah, that’s, that’s lovely. We heard that BMC had to stop accepting critical care patients this weekend. Who else has had to do that?
PAUL BIDDINGER: So, I think it’s about transfer of where patients are going and kind of releveling. So, Boston Medical Center has transferred some patients. We’re actually, I think, transferring some patients down from the North Shore today. I think it’s going to be different on different days.
Q: Thank you.
MODERATOR: Alright, it looks like we have no further questions. If that’s the case, thank you, Dr. Biddinger. Do you have any other final words, you’d like to say?
PAUL BIDDINGER: No, I, well, I’ll say them anyway. You know, this has been an extraordinary time. And in medicine, I think every hospital has done things they likely thought they never would have to do in order to make ICU space, ED space, hospital space available, and to have systems in place to make sure they protect their workers, while they’re delivering this care.
And there’s a lot of good in the horrible impact that this outbreak is having on society. Overall, just to see what the healthcare community has been capable of and I’m really glad that across the city, across the state, hospitals have come together to take actions like the ones we’ve been talking about today.
So, hopefully again, we won’t see the worst of this and I’m thrilled that what’s been done so far really has made sure that we can care for everyone who’s become ill with COVID in Massachusetts.
This concludes the April 9 press conference.
Benjamin Sommers, professor of health policy and economics (April 6, 2020)