The inside of a tent set up to treat respiratory patients at Renown Regional Medical Center in Reno on Thursday, March 12, 2020.
As the number of confirmed cases of the novel coronavirus climbs and all non-essential business grinds to a halt in Nevada, health care providers across the state are continuing to prepare for a massive influx of critically ill patients.
Providers, in interviews with The Nevada Independent this week, said they are already seeing an uptick in emergency room and urgent care visits, though those facilities have yet to be overwhelmed as they have been in Washington state and Italy. The most significant challenges at this point, they said, are the shortage of testing resources and personal protective equipment, as well as a surge of minorly ill patients seeking to be tested for coronavirus.
Dr. Bret Frey, president of the Nevada chapter of the American College of Emergency Physicians, said that emergency room physicians in the state have not yet seen a “significant rise” in severe respiratory patients, but are anticipating that it's soon to come.
“We're starting to approach the very steep part of the curve,” said Frey, referring to the epidemiological curve that shows how quickly an outbreak is spreading in a community. “This is a mathematical problem, from my perspective. We just don't know in Las Vegas, Reno and elsewhere how fast the caseload is truly doubling.”
So far, there have been 55 confirmed cases of the novel coronavirus in the state of Nevada, including 42 in Clark County, 12 in Washoe County and one in Carson City, and one confirmed death. But it's hard for providers and other health officials to know how quickly the state is moving up that epidemiological curve with testing still fairly limited.
“If you do the math, by the end of this month we could have a significant number of not just identified positives but community positives that haven't been tested,” Frey said. “And even if only a small percentage of those require significant respiratory support, you can see how we need to move the chess pieces now to prepare for the next two to four weeks.”
But healthcare providers in both hospital and urgent care settings have anecdotally seen an increase in patients with respiratory symptoms over the last couple of weeks at a time when flu season should be tapering off.
Dr. Shadaba Asad, medical director of infectious disease at University Medical Center, said that almost all patients who are admitted to the hospital with respiratory symptoms are being tested for COVID-19.
“At this point, the likelihood of other viral infections is becoming lower,” Asad said. “We're almost at the tail end of flu season now.”
However, only some patients actually end up being admitted to the hospital after undergoing screening for the virus. Upon showing up to UMC's emergency room, patients are triaged and, if they are experiencing fever, cough and shortness of breath, the usual symptoms of COVID-19, they are handed a mask to wear along with a yellow card and are directed to UMC's special screening unit inside the hospital.
When they arrive at the unit — which is a negative pressure space, designed to keep pathogens contained within it, and in close proximity to the ER and ICUs should a patient take a turn for the worse and need quick assistance — they present the yellow card to gain entry. The unit has its own dedicated registration staff, nursing staff and ER physician to interview patients and decide the best course of action.
Asad said that patients with a mild infection who don't have a high fever, look well and are breathing comfortably will be provided detailed instructions from the Centers for Disease Control and Prevention's website and instructed to self-isolate at home and follow up with health officials. Patients who have a high fever, are having trouble breathing or are someone who is at a higher risk of complications from COVID-19 because of their age or underlying conditions are likely to be admitted and undergo complete testing, evaluation and admission to the hospital.
“Honestly, there is very limited testing available in the state,” Asad said. “We're trying to reserve it for our sickest patients.”
Heather Simonson, a physician assistant in Clark County, is seeing a similar situation at the urgent care where she works. She said that after an expected drop off in flu cases about three weeks ago, she started to see an uptick in respiratory cases.
She said she has had a growing number of patients over the last week who have screened positive for COVID-19 — meaning they have the symptoms of the virus and either have traveled recently or had contact with someone who tested positive for coronavirus — and who are testing negative for other respiratory illnesses, such as the seasonal flu. The group that's appeared to be hardest hit in her experience, she said, is healthy men in their 40s, 50s and 60s who are fine one day and a couple of days later have pneumonia.
But with a limited number of tests at her clinic, it's hard for Simonson to know who has the virus and who doesn't.
“Now I'm looking back, I've had these patients for weeks, and I know that's what it is based on how sick they were,” Simonson said.
She said that the original protocol put forward by the Southern Nevada Health District — where providers were supposed to call to notify the district when a patient screened positive and transfer them by ambulance to a local hospital for testing — quickly fell apart: By Wednesday, no one was answering the health district's line, and it wasn't accepting any voicemails either.
A health district spokeswoman said in an email that they have been “working diligently” to respond to calls from health care providers, patients, health care facilities, “the worried well,” and others that have, at times, pushed the district beyond its limits. She said the health district has provided updated guidance to health care providers that they no longer need to call the health district to discuss whether they should order COVID-19 tests and that the decision should be based on their clinical judgment.
Simonson also noted the delay she's experienced in getting results back for the patients she has been able to test, with her first patient's test still outstanding a week after she had seen him. She added that her clinic has run out of N95 respirator masks and is instead doing the best they can with surgical masks, gloves and handwashing.
“At this point, we're not going to be able to stop it, but we need to slow down the spread,” Simonson said.
On the primary care side, Dr. John Rhodes, the senior medical director of primary care for Southwest Medical, said that the number of patients coming into clinics has been manageable, largely because of concerted efforts to divert patients with COVID-19-like symptoms to more appropriate settings to be tested. Southwest Medical is encouraging patients to use its tele-health NowClinic to be screened for COVID-19 and, if the provider deems it necessary, set up an appointment to come in for drive-up testing outside of one of the company's in-person clinics.
“We are trying to screen our patients before they get here to see if they have any at risk symptoms, trying to triage that to get them at the appropriate level of care so they don't expose our other patients, vulnerable patients, or our medical teams so we don't end up having to have people go into self-isolation for a period of time,” Rhodes said.
He added that Southwest Medical has stationed staff at the entrance to each clinic to screen patients and, if they are exhibiting symptoms consistent with COVID-19, give them a mask and take them to a designated area to wait. Southwest Medical's clinics keep a “limited number” of tests on hand for coronavirus, he said, which are generally processed in about 72 hours by Quest Diagnostics, the commercial lab with whom they have a contract.
“We've been able to have the kits for those that really need to be tested,” Rhodes said.
Unlike Simonson's clinic, Rhodes said that Southwest Medical still has N95 masks, but that they're carefully monitoring their supplies.
“We're no different than everyone else. We have to be careful with the amount of (personal protective equipment) we have,” Rhodes said. “It's no secret that we have a shortage of it nationally.”
Though he works on the primary care side, he said that Southwest Medical is continuing to evaluate how their staffing is matching up with patients' needs for urgent care services.
“If that means asking some of our primary care doctors to help in convenient cares or urgent cares, then that's what we will do,” Rhodes said. “We're looking at all potential options and trying to be prepared, as fluid as this process has been and unpredictable as it's been.”
Hospitals, too, are doing their best to be prepared. Frey said that personal protective equipment in emergency departments is “being consumed at a rapid rate” that will only increase as the number of cases in the state grows.
He also acknowledged concerns about the number of ventilators, used to help patients breathe, in hospitals across the state — a figure that's hard to pin down as it's not something hospitals are required to publicly report.
“What I will say is every system has a finite number of ventilators and a finite number of resources,” Frey said.
UMC, for instance, has 125 ventilators with a “large order coming in” that will significantly increase the hospital's capacity, a spokesman said in an email. In total, the hospital has 541 hospital beds, including 143 ICU beds, though that latter number can be significantly increased in the event of an emergency.
Asad said the hospital is “not at capacity right now” and easily able to handle additional patients at this point. However, she said the hospital is in the coming days and weeks “expecting a surge of patients” and that their top priority right now is preparing for that surge.
At this point, the biggest strain on hospitals has not been from critically ill patients experiencing a true emergency but from minorly ill patients showing up to emergency rooms hoping to be tested for COVID-19. Frey said that hospitals “don't have widespread capability for that” at this point, and probably won't for another two to four weeks.
“The sense I have from my Southern Nevada colleagues, as well as locally here in Reno, is we're starting to see a rise in concerned individuals who do not have a threat to life or limb and are not in functional decline coming to the ER for testing and to answer questions about coronavirus,” Frey said. “That's going to be a difficult thing to manage numerically if it grows if that subset of people grows and shows up en masse.”
Just as UMC has dedicated a special wing to screening patients, other hospitals, including the three in Las Vegas run by HCA, have set up outdoor tents to screen and triage patients who show up with respiratory symptoms. However, HCA has not had to put those tents into use yet, spokeswoman Jennifer McDonnel said in an email on Tuesday.
“At all of our hospitals we are seeing flu-like symptoms which is typical for this time of year,” she said.
Hospitals across Las Vegas are also putting additional protocols into place, including implementing screening processes for visitors, as is the case for HCA hospitals in Las Vegas, or banning them altogether, as the Southern Nevada VA Healthcare System has done, with only limited exceptions for veterans in their last stages of life.
The VA in Southern Nevada has also canceled elective surgeries and other non-urgent procedures.
In rural Nevada — where it takes even longer to get the results of tests because samples have to be taken by courier to Reno once a day — hospitals and doctors are also taking an abundance of caution with respiratory patients and having them isolate at home.
“There are so many viruses that can cause lower respiratory tract infections,” said Dr. Robin Titus, the health officer for Lyon County. “We're treating them as presumptive positive.”
At this point, providers are cautiously hopeful that the strict social distancing measures the state has put in place, including halting all non-essential business as of noon on Wednesday, will help stem the tide of coronavirus in the Silver State — and that coupled with the efforts undertaken by hospitals they will be prepared to weather the incoming storm.
“I'm just hoping that between the community doing their part, which is slowing the progression of the disease — I just hope they understand how vital their contribution is,” Asad said, “and hospital and health care providers doing their part, in maximizing their capacity to deal with this outbreak, I'm positive we can actually stop this catastrophe.”
-->As the number of confirmed cases of the novel coronavirus climbs and all non-essential business grinds to a halt in Nevada, health care providers across the state are continuing to prepare for a massive influx of critically ill patients.
Providers, in interviews with The Nevada Independent this week, said they are already seeing an uptick in emergency room and urgent care visits, though those facilities have yet to be overwhelmed as they have been in Washington state and Italy. The most significant challenges at this point, they said, are the shortage of testing resources and personal protective equipment, as well as a surge of minorly ill patients seeking to be tested for coronavirus.
Dr. Bret Frey, president of the Nevada chapter of the American College of Emergency Physicians, said that emergency room physicians in the state have not yet seen a “significant rise” in severe respiratory patients, but are anticipating that it's soon to come.
“We're starting to approach the very steep part of the curve,” said Frey, referring to the epidemiological curve that shows how quickly an outbreak is spreading in a community. “This is a mathematical problem, from my perspective. We just don't know in Las Vegas, Reno and elsewhere how fast the caseload is truly doubling.”
So far, there have been 55 confirmed cases of the novel coronavirus in the state of Nevada, including 42 in Clark County, 12 in Washoe County and one in Carson City, and one confirmed death. But it's hard for providers and other health officials to know how quickly the state is moving up that epidemiological curve with testing still fairly limited.
“If you do the math, by the end of this month we could have a significant number of not just identified positives but community positives that haven't been tested,” Frey said. “And even if only a small percentage of those require significant respiratory support, you can see how we need to move the chess pieces now to prepare for the next two to four weeks.”
But healthcare providers in both hospital and urgent care settings have anecdotally seen an increase in patients with respiratory symptoms over the last couple of weeks at a time when flu season should be tapering off.
Dr. Shadaba Asad, medical director of infectious disease at University Medical Center, said that almost all patients who are admitted to the hospital with respiratory symptoms are being tested for COVID-19.
“At this point, the likelihood of other viral infections is becoming lower,” Asad said. “We're almost at the tail end of flu season now.”
However, only some patients actually end up being admitted to the hospital after undergoing screening for the virus. Upon showing up to UMC's emergency room, patients are triaged and, if they are experiencing fever, cough and shortness of breath, the usual symptoms of COVID-19, they are handed a mask to wear along with a yellow card and are directed to UMC's special screening unit inside the hospital.
When they arrive at the unit — which is a negative pressure space, designed to keep pathogens contained within it, and in close proximity to the ER and ICUs should a patient take a turn for the worse and need quick assistance — they present the yellow card to gain entry. The unit has its own dedicated registration staff, nursing staff and ER physician to interview patients and decide the best course of action.
Asad said that patients with a mild infection who don't have a high fever, look well and are breathing comfortably will be provided detailed instructions from the Centers for Disease Control and Prevention's website and instructed to self-isolate at home and follow up with health officials. Patients who have a high fever, are having trouble breathing or are someone who is at a higher risk of complications from COVID-19 because of their age or underlying conditions are likely to be admitted and undergo complete testing, evaluation and admission to the hospital.
“Honestly, there is very limited testing available in the state,” Asad said. “We're trying to reserve it for our sickest patients.”
Heather Simonson, a physician assistant in Clark County, is seeing a similar situation at the urgent care where she works. She said that after an expected drop off in flu cases about three weeks ago, she started to see an uptick in respiratory cases.
She said she has had a growing number of patients over the last week who have screened positive for COVID-19 — meaning they have the symptoms of the virus and either have traveled recently or had contact with someone who tested positive for coronavirus — and who are testing negative for other respiratory illnesses, such as the seasonal flu. The group that's appeared to be hardest hit in her experience, she said, is healthy men in their 40s, 50s and 60s who are fine one day and a couple of days later have pneumonia.
But with a limited number of tests at her clinic, it's hard for Simonson to know who has the virus and who doesn't.
“Now I'm looking back, I've had these patients for weeks, and I know that's what it is based on how sick they were,” Simonson said.
She said that the original protocol put forward by the Southern Nevada Health District — where providers were supposed to call to notify the district when a patient screened positive and transfer them by ambulance to a local hospital for testing — quickly fell apart: By Wednesday, no one was answering the health district's line, and it wasn't accepting any voicemails either.
A health district spokeswoman said in an email that they have been “working diligently” to respond to calls from health care providers, patients, health care facilities, “the worried well,” and others that have, at times, pushed the district beyond its limits. She said the health district has provided updated guidance to health care providers that they no longer need to call the health district to discuss whether they should order COVID-19 tests and that the decision should be based on their clinical judgment.
Simonson also noted the delay she's experienced in getting results back for the patients she has been able to test, with her first patient's test still outstanding a week after she had seen him. She added that her clinic has run out of N95 respirator masks and is instead doing the best they can with surgical masks, gloves and handwashing.
“At this point, we're not going to be able to stop it, but we need to slow down the spread,” Simonson said.
On the primary care side, Dr. John Rhodes, the senior medical director of primary care for Southwest Medical, said that the number of patients coming into clinics has been manageable, largely because of concerted efforts to divert patients with COVID-19-like symptoms to more appropriate settings to be tested. Southwest Medical is encouraging patients to use its tele-health NowClinic to be screened for COVID-19 and, if the provider deems it necessary, set up an appointment to come in for drive-up testing outside of one of the company's in-person clinics.
“We are trying to screen our patients before they get here to see if they have any at risk symptoms, trying to triage that to get them at the appropriate level of care so they don't expose our other patients, vulnerable patients, or our medical teams so we don't end up having to have people go into self-isolation for a period of time,” Rhodes said.
He added that Southwest Medical has stationed staff at the entrance to each clinic to screen patients and, if they are exhibiting symptoms consistent with COVID-19, give them a mask and take them to a designated area to wait. Southwest Medical's clinics keep a “limited number” of tests on hand for coronavirus, he said, which are generally processed in about 72 hours by Quest Diagnostics, the commercial lab with whom they have a contract.
“We've been able to have the kits for those that really need to be tested,” Rhodes said.
Unlike Simonson's clinic, Rhodes said that Southwest Medical still has N95 masks, but that they're carefully monitoring their supplies.
“We're no different than everyone else. We have to be careful with the amount of (personal protective equipment) we have,” Rhodes said. “It's no secret that we have a shortage of it nationally.”
Though he works on the primary care side, he said that Southwest Medical is continuing to evaluate how their staffing is matching up with patients' needs for urgent care services.
“If that means asking some of our primary care doctors to help in convenient cares or urgent cares, then that's what we will do,” Rhodes said. “We're looking at all potential options and trying to be prepared, as fluid as this process has been and unpredictable as it's been.”
Hospitals, too, are doing their best to be prepared. Frey said that personal protective equipment in emergency departments is “being consumed at a rapid rate” that will only increase as the number of cases in the state grows.
He also acknowledged concerns about the number of ventilators, used to help patients breathe, in hospitals across the state — a figure that's hard to pin down as it's not something hospitals are required to publicly report.
“What I will say is every system has a finite number of ventilators and a finite number of resources,” Frey said.
UMC, for instance, has 125 ventilators with a “large order coming in” that will significantly increase the hospital's capacity, a spokesman said in an email. In total, the hospital has 541 hospital beds, including 143 ICU beds, though that latter number can be significantly increased in the event of an emergency.
Asad said the hospital is “not at capacity right now” and easily able to handle additional patients at this point. However, she said the hospital is in the coming days and weeks “expecting a surge of patients” and that their top priority right now is preparing for that surge.
At this point, the biggest strain on hospitals has not been from critically ill patients experiencing a true emergency but from minorly ill patients showing up to emergency rooms hoping to be tested for COVID-19. Frey said that hospitals “don't have widespread capability for that” at this point, and probably won't for another two to four weeks.
“The sense I have from my Southern Nevada colleagues, as well as locally here in Reno, is we're starting to see a rise in concerned individuals who do not have a threat to life or limb and are not in functional decline coming to the ER for testing and to answer questions about coronavirus,” Frey said. “That's going to be a difficult thing to manage numerically if it grows if that subset of people grows and shows up en masse.”
Just as UMC has dedicated a special wing to screening patients, other hospitals, including the three in Las Vegas run by HCA, have set up outdoor tents to screen and triage patients who show up with respiratory symptoms. However, HCA has not had to put those tents into use yet, spokeswoman Jennifer McDonnel said in an email on Tuesday.
“At all of our hospitals we are seeing flu-like symptoms which is typical for this time of year,” she said.
Hospitals across Las Vegas are also putting additional protocols into place, including implementing screening processes for visitors, as is the case for HCA hospitals in Las Vegas, or banning them altogether, as the Southern Nevada VA Healthcare System has done, with only limited exceptions for veterans in their last stages of life.
The VA in Southern Nevada has also canceled elective surgeries and other non-urgent procedures.
In rural Nevada — where it takes even longer to get the results of tests because samples have to be taken by courier to Reno once a day — hospitals and doctors are also taking an abundance of caution with respiratory patients and having them isolate at home.
“There are so many viruses that can cause lower respiratory tract infections,” said Dr. Robin Titus, the health officer for Lyon County. “We're treating them as presumptive positive.”
At this point, providers are cautiously hopeful that the strict social distancing measures the state has put in place, including halting all non-essential business as of noon on Wednesday, will help stem the tide of coronavirus in the Silver State — and that coupled with the efforts undertaken by hospitals they will be prepared to weather the incoming storm.
“I'm just hoping that between the community doing their part, which is slowing the progression of the disease — I just hope they understand how vital their contribution is,” Asad said, “and hospital and health care providers doing their part, in maximizing their capacity to deal with this outbreak, I'm positive we can actually stop this catastrophe.”
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