Weekly Global COVID-19 Update: Part 2

Presented byVidal Seegobin, Global Forum for Health Care Innovators

What you need to know in 30 minutesWeekly Global COVID-19 Update: Part 2

April 20, 2020

© 2020 Advisory Board • All rights reserved • advisory.com

Today’s Research Expert

Vidal SeegobinPractice Manager, International Research

Vidal is a practice manager on the Global Forum for Health Care Innovators—Advisory Board International's health care strategy programme. Prior to joining the Advisory Board, he worked as a researcher on disease surveillance and pandemic response. He holds a master's degree in international economics from American University and a bachelor's degree in international business from Carleton University in Ottawa, Canada.

[email protected] @SeegobiV

Vidal photo

http://www.advisory.com/



6

Source: Batia A, “Trajectory of COVID-19 Confirmed Cases,” updated 17 April 2020; Minutephysics, “How To Tell If We're Beating COVID-19,” Youtube.com, 27 March 2020; “Coronavirus Disease (COVID-19) – Statistics and Research,” updated 16 April 2020.

COVID beginning to drop off in US and Western Europe

Advisory Board interviews and analysis.

10

100

1,000

10,000

100,000

100 1,000 10,000 100,000 1,000,000

AustraliaSouth Korea

Canada

France Italy

Spain

U.S.

500,000

Total confirmed cases

New

cas

es in

the

past

wee

k

Country Total deathsper million

Spain 409

Italy 367

France 274

UK 202

US 100

Germany 46

Canada 32

South Korea 4.5

Australia 2.5

New Zealand 2.2

New cases vs total cases amplifies which countries are deviating from exponential growth ‘conveyer belt’

COVID grows at the same exponential rate in nearly all countries

Exponential growth rate

Countries drop off ‘conveyer belt’ as growth in cases is no longer exponential

New Zealand



https://aatishb.com/covidtrends/

https://www.youtube.com/watch?v=54XLXg4fYsc

https://ourworldindata.org/coronavirus


7

Source: “Here are the businesses that can start reopening in Italy,” The Local, 14 April 2020; Woods A, “Spain loosens coronavirus restrictions as nearly 300,000 return to work,” New York Post, 14 April 2020; “Coronavirus: Austria and Italy reopen some shops as lockdown eased,” BBC News, 14 April 2020; Murray A, “Coronavirus: Why Denmark is taking steps to open up again,” BBC News, 12 April 2020; “Coronavirus in Berlin: the current situation, how to prepare and more,” All About Berlin, 16 April 2020; Berglund N, “Norway cleared to gradually reopen,” newsinenglish.no, 7 April 2020; Němec L, “Breaking: Czech government outlines five-step plan for re-opening shops, restaurants,” Expats CZ, 14 April 2020; Sills B, “How European countries plan to reopen their economies from the coronavirus lockdown,” Fortune, 14 April 2020; Norman G, “Switzerland announces dates for its economy to start reopening during coronavirus outbreak,” Fox News, 16 April 2020.

Only a few countries starting with health careAs Europe reopens, variation in which measures lifted first


Country Date of first lift First measures lifted Future plans to reopen

Italy 13 April Bookshops, children's clothing shops, dry cleaners, laundromats all madeessential businesses; most manufacturers reopening

Several regions (e.g., Lombardy) delaying opening these industries

Spain 13 April 300,000 people who cannot work from home (incl. construction and manufacturing industries) allowed to return to work in Madrid NA

Austria 14 April Shops <400 m2, hardware stores, and garden centres can reopen Larger shopping centres opening on 1 May; targeting mid-May for restaurants and hotels

Denmark 15 April Children aged 11 and younger return to schools and nurseries/day care; Hospitals start to conduct non-critical procedures NA

Norway 20 April Day care centers can re-open; Lift on Hytte ban;Opticians and physiotherapists can begin operating

Hair and skin-care salons, high schools begin reopening on 27 April; Cultural and sporting

events banned at least until 15 June

Czech Republic 20 April Farmers markets, trade shops, car shops, outdoor athletic areas for

professionals (without spectators), and weddings of up to 10 peopleFive-part plan reopens country over April and May, with the last restrictions lifted on 8 June

Germany 20 April Bike shops, garages, bookstores, and other stores less than 800 m2 can reopen Schools to begin reopening on 4 May; all “major events” forbidden until 31 August

Switzerland 27 AprilHospitals to resume non-urgent care and outpatient procedures, such as dental work and physical therapy; hairdressers, massage studios,

hardware stores, garden centers allowed to reopen

Primary schools and shops opening on 11 May; Secondary schools, vocational colleges,

universities, and museums opening on 8 June



https://www.thelocal.it/20200414/here-are-the-businesses-that-can-start-reopening-in-italy

https://nypost.com/2020/04/14/spain-loosens-coronavirus-restrictions-as-thousands-return-to-work/

https://www.bbc.com/news/world-europe-52275959

https://www.bbc.com/news/world-europe-52226763

https://allaboutberlin.com/guides/coronavirus

https://www.newsinenglish.no/2020/04/07/norway-cleared-to-gradually-reopen/

https://news.expats.cz/coronavirus-in-the-czech-republic/breaking-czech-government-outlines-five-step-plan-for-re-opening-shops-restaurants/

https://fortune.com/2020/04/14/europe-austria-denmark-spain-france-reopen-economy-coronavirus-lockdown/

https://www.foxnews.com/world/switzerland-announces-dates-for-its-economy-to-start-re-opening-during-coronavirus-outbreak


8

Source: “Malaysia turns to coronavirus antibody tests to supplement laboratory checks”, WHBL, April 14, 2020; T You, “Chinese police wear smart helmets equipped with AI-powered infrared cameras to detect pedestrians with fevers as they patrol the streets amid coronavirus crisis”, Daily Mail, March 4, 2020; Singapore Government, “Help speed up contact tracing with TraceTogether”, Gov.sg, March 21, 2020.

Solutions needed for three unanswered questions to phase out social distancingWhat do we need to know if we can reopen?

Who is immune? How is it spreading?Who has it and doesn’t know?

Antibody testsTo understand community spread and immunity levels in the population

What is needed to reopen,

state-by-state

What’s in the way of doing

more?

Disease surveillanceTo scan populations broadly for early symptoms and collect data

Scaled contact tracingTo isolate those who may have been exposed to symptomatic people

TraceTogetherSingaporean app tracks contact between people using phone Bluetooth

Where it’s already

happening

Smart helmetsChinese police wear smart helmets equipped to check pedestrians for fevers

Few commercially available, government-approved tests

MalaysiaAntibody tests used in conjunction with PCR1 tests during quarantine periods

Training and deploying newly idled government workers

Potential infringement on personal privacy laws


1. Polymerise chain reaction.




9

Source: C Hodgson and G Parker, “UK government admits Covid-19 antibody tests don’t work”, Financial Times, April 6, 2020; S Jones, “Coronavirus test kits withdrawn in Spain over poor accuracy rate”, The Guardian, March 27, 2020; G Chazan and D Mancini, “Germany to run Europe’s first large-scale antibody test programme”, Financial Times, April 9, 2020.

Progress yet to be made before promise of antibody tests can be realisedSerology testing has hit bumps in the road


Effectiveness of serology tests still unknown1

32,000Blood samples in Germany will be analysed as part of antibody test programme

38,000Beaumont Health employees in a study on health care worker susceptibility and antibody response

Presence of antibodies doesn’t guarantee immunity 2

Challenges with serology tests for Covid-19

Large-panel antibody studies underway

"We simply don't know yet what it takes to be effectively protected from this infection."

Dawn Bowdish, Professor Pathology and Molecular Medicine, McMaster University, Canada

17.5 million serology tests ordered by UK government have all been proven ineffective

Spanish government recalled 58,000 serology testing kits from China after discovering accuracy rate was 30%

More than 4,000 samples gone untested in Telluride, Colorado, US after New York-based lab closed due to COVID-19 infections




10

1 Needs strong testing capacity to determine Covid-19 positives3User data privacy concerns, especially in

EU, US, and UK, may prevent approval

2 Low adoption rates in voluntary contact tracing schemes could limit efficacy

5 Tools capable of amplifying false positives or negatives

6 Technology could come too late

Source: L Kelion, “Apple and Google team up to contact trace Covid-19”, BBC, April 10, 2020; J Taylor, “Australia’s coronavirus contact tracing app”, Guardian, April 16, 2020; R Cohen, “1.5 million Israelis using voluntary coronavirus monitoring app”, Reuters, April 1, 2020.

But apps unlikely to be a ‘silver bullet’ for COVID-19Contact tracing tech a promising way of easing restrictions


Uses anonymised Bluetooth smartphone infrastructure to alert user if they have been within close proximity (~2 m) of an infected person

How contact tracing tools work

Significant limitations may hinder success

4 Many stakeholders in the public health ecosystem need to agree on common approach

Contact tracing technology gaining traction

Apple and Google undertake massive contact tracing project (3.5bn devices); hope to integrate with existing national tools

Australian government developing voluntary contact tracing tool based on Singapore’s Trace Together app

1.5M Israelis use the government’s HaMagen app; Germany, UK, and Chile are basing their technology on the software




11

Three patient ‘crunches’ moving forward


First step is solidifying your COVID pathways and staffing arrangements

Challenge: Surge in delayed procedures while productivity dips due to sanitation re-quirements and scarce PPE; must treat all patients as COVID-positive upon enteringImperatives: • Have a plan for identifying and

recapturing delayed/cancelled cases• Minimise any unnecessary variation or

inefficiencies (for all case types) to preserve resources

• Prioritise provider wellbeing—accommodating pent-up demand will take a healthy, engaged workforce—right when everyone needs a vacation

Immediate: COVID crunch

Challenge: Sudden influx of COVID patients requiring isolation and new pathways; some systems on the financial hook without elective revenue to offset lossesImperatives: • Activate alternative sites of care e.g.,

virtual channels, outlying facilities• Configure to accept as much of COVID-

19 demand surge as possible • Minimise any unnecessary complications

or inefficiencies (for all conditions) to preserve resources

Imminent: Elective crunch

Looming: Complexity crunch

Challenge: Chronic patients flood system after foregoing care for months, rise in latent disease due to delayed diagnostics and COVID complications; must treat all patients as COVID-positive upon enteringImperatives (start now): • Shift all scheduled visits to virtual option• Analyse March/April diagnostic and

follow-up visit drop-off compared to years’ past to estimate size, timeline of crunch

• Begin crunch planning with post-acute and primary care partners immediately

• Extend specialty and care management training (virtual is an option) to community providers needing to manage higher-complexity patients post-discharge




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Where your peers are sending their COVID patients

Non-hospital health care facilities Non-health care facilities

Designate off-site screening and treatment centers: Urgent care centers can absorb COVID testing responsibilities or serve as respiratory illness-only clinics

Repurpose hotels, dorms to house patients: Facilities have existing private rooms, bathrooms, laundry, cleaning, and food service capabilities

Build treatment space within convention centers, arenas, stadiums: Existing infrastructure, workforce allows for quick repurposing to large treatment facility

Create testing, treatment sites in large open spaces (e.g., parks, fields, parking lots): Allows hospitals to utilise open space close to existing facilities to streamline patient and staff transfer

Transition specific patients or services to other care sites: Outpatient clinics can absorb specific urgent surgical and medical volumes

Lean on primary care providers for non-urgent issues: GPs can manage ongoing primary care needs via telehealth


To access a COVID-19 checklist to expand capacity, visit advisory.com/covid19




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Direct patients to remote triage and virtual visits first

• Assessment tool identifies patient in need of virtual visit• NP provides in-depth consultation over live video• Hospital has protocol to safely transfer patient without

infecting others

Severe cases

• Assessment tool identifies patients to self-care at home• Telehealth team monitors patient at home using virtual

visits and some form of remote monitoring

Mild cases

• Chatbot prepopulated with FAQs addressingsymptoms, self-isolation, and other common worries

• Most users don’t have to talk to a physician

Worried well

Providence St. Joseph’s COVID-19 chatbot

Chatbots increase clinical capacity to focus on severe cases

Invested heavily in pointing patients to the chatbot, and gave it prominent positioning on Providence website

Preparing to scale up tech capabilities and staffing as number of infected patients increase


Source: Providence St. Joseph Health, Renton, WA.




15Source: “COVID-19 Hospital Discharge Service Requirement”, NHS England, March 19, 2020.

Support post-acute providers to help drive throughputUK created national discharge strategy to ease concerns

NHS England’s hospital discharge model

1

2

NHS centrally funds the cost of new or extended out-of-hospital health and social care support packages

Create a Discharge to Assess model based on four pathways:

Eliminate transfer barriers – namely funding and pathway ambiguity – to efficiently discharge from acute settingGoal

How they’re doing it


3 Delineate clear responsibilities across the health and social care system:• Acute hospitals will be responsible for

leading on the discharge of all patients on pathway 0, ensuring that 50% of patients who need minimal support can leave the hospital on time

• Community providers will lead on pathways 1-3 as they will play a key rolein providing the required rehabilitation support at home

Pathway 0: 50% of people simply discharged home, no input from health system

Pathway 1: 45% of people need health and social care rehab support at home

Pathway 3: 1% of people cannot be discharged, remain in palliative care

Pathway 2: 4% of people receive rehabilitation in bedded setting




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1. Post-traumatic stress disorder.Source: E Cheung, “Some recovered patients may have reduced lung function”, South China Morning Post, March 13, 2020; A Murray, et al., “We need a Nightingale model for rehab after covid-19”, HSJ, April 8, 2020.

Half of recovering COVID patients will require some form of ongoing careDischarge strategy must consider long-term rehabilitation


1Successfully discharge

Support post-acute recovery with staff and resources in order to:• Improve long-term outcomes for survivors• Reduce risk of hospital readmission• Maintain maximum capacity at acute hospitals

2Support rehabilitation

Transfer COVID-19 patients out of the hospital

Steps for managing COVID-19 survivors

30-80% of ICU survivors experience cognitive impairment

25-80% of ICU survivors develop a new physical impairment

20-30% of COVID survivors have re-duced lung function

ICU survivors may experience PTSD1, anxiety, depression




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1. With at least one year of graduate medical education. Source: 76,000 Healthcare Workers Have Volunteered to Help NY Hospitals Fight Coronavirus, Forbes, March 29, 2020.

NY deploys variety of strategies to increase clinician supply


Sampling of strategies deployed by New York to increase clinician supply

Over 70,000 medical volunteers answered the call

Asking retired medical professionals to volunteer

Relaxing licensure requirements for out-of-state clinicians

Allowing NPs to practice without physician oversight

Allowing students to volunteer without a clinical affiliation agreements

Removing limits on working hours for physicians

Allowing foreign graduates1 to provide care without licenses

30,000+ Registered

Nurses

8,000+Physicians

6,000+Licensed

Practical Nurses

3,000+Nurse

Practitioners

1,000+Physician Assistants

12,000+ Mental health professionals




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Source: NHS Employers, “Enabling staff movement,” 8 April 2020; Advisory Board, “4 Ways Allegheny Health Network is flexing its nurse staffing for the Covid-19 surge,” 7 April 2020.

A flexible staffing approach is your new baselineSystems, governments use creative strategies to redeploy staff


Allegheny Health Network’s nurse extender strategy NHS England lowering barriers to shift staff

Redeployed nurses work as ‘nurse extenders’, with one nurse extender for every two ICU nurses and one extender for every three nurses in all other units

Digital ‘staff passports’ will create an embedded licence to attend agreement and store verified credentials on health care workers’ smartphones

Fast-tracking initiative that makes it easier for health care workers to move between organisations to meet COVID-19 need

OR and ambulatory site nurses redeployed toacute care

Responsibilities include communicating with patients’ families, relieving nurses for breaks, and assisting with the donning and doffing of PPE

Goal of passport program is to help NHS organisations move staff safely, quickly, and ‘without unnecessary bureaucracy’



https://www.nhsemployers.org/covid19/enabling-staff-movement

https://www.advisory.com/daily-briefing/2020/04/07/Allegheny


19

Quarantined patients are kept away from mainbuilding in a field hospital, wherecare is delivered through a robotic telemedicine cart

Protect providers across facilities with virtual solutions

Doctors monitor patients from dashboards in the main hospital building, protecting doctors from additional exposure to infection

Doctors decide if the patient can be treated at home with RPM and virtual visits or if they need to be admitted and treated in quarantine

Remote monitoring• Sensor patches measures

heart rate and motion• Tyto Care devices

measure blood pressure

Communication• TV for video conferencing• Phones• Emergency buttons• Security cameras

Sheba Medical Center’s telehealth programme

RPM1 and robotics allow providers to deliver necessary care at a distance

Source: Sheba Medical Center, Ramat Gan, Israel.


1. Remote patient monitoring.




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Three patient ‘crunches’ moving forward


Assessing potential cases after COVID surge passes

Challenge: Surge in delayed procedures while productivity dips due to sanitation re-quirements and scarce PPE; must treat all patients as COVID-positive upon enteringImperatives: • Have a plan for identifying and

recapturing delayed/cancelled cases• Minimise any unnecessary variation or

inefficiencies (for all case types) to preserve resources

• Prioritise provider wellbeing—accommodating pent-up demand will take a healthy, engaged workforce—right when everyone needs a vacation

Immediate: COVID crunch

Challenge: Sudden influx of COVID patients requiring isolation and new pathways; some systems on the financial hook without elective revenue to offset lossesImperatives: • Activate alternative sites of care e.g.,

virtual channels, outlying facilities• Configure to accept as much of COVID-

19 demand surge as possible • Minimise any unnecessary complications

or inefficiencies (for all conditions) to preserve resources

Imminent: Elective crunch

Looming: Complexity crunch

Challenge: Chronic patients flood system after foregoing care for months, rise in latent disease due to delayed diagnostics and COVID complications; must treat all patients as COVID-positive upon enteringImperatives (start now): • Shift all scheduled visits to virtual option• Analyse March/April diagnostic and

follow-up visit drop-off compared to years’ past to estimate size, timeline of crunch

• Begin crunch planning with post-acute and primary care partners immediately

• Extend specialty and care management training (virtual is an option) to community providers needing to manage higher-complexity patients post-discharge




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1. Includes type 1-3 A&E attendances, type 1-4, and other emergency admissions.2. Percutaneous coronary intervention.3. ST-Elevation Myocardial Infarction.

Source: NHS England, “A&E Attendances and Emergency Admissions: Time series”, March 20, 2020; Rodriguez-Leor, et al., “Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España”, Revista Española de Cardiología, April 2, 2020; J Bakker, “Lives at risk due to 50% drop in heart attack A&E attendance”, British Heart Foundation, April 9, 2020; D Campbell, et al., “Warning as UK coronavirus outbreak leads to sharp rise in deaths at home”, Guardian, April 16, 2020.

Social distancing and fear of infection keeping people away from health care COVID-19 already impacting non-elective utilisation

NHS England total A&E attendances and emergency admissions Q4-Q1, 2015-201

1,247

429644

258

PCI STEMI

February 24 - March 1 March 16 - March 22

Number of cardiology interventions in Spain before and during COVID-19 pandemic


48%

Oct Nov Dec Jan Feb Mar

2015/16 2016/17 2017/18 2018/19 2019/20

2.3M2.2M

1.6M

2.1M

Covid-19

DATA SPOTLIGHT

Additional cardiac arrest deaths per day in London since beginning of April85

71% of cardiologists believe patients are afraid to visit the hospital due to Covid-19

2 3




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1. Based on study of 500 Italian cancer patients.2. Treatments included chemotherapy and radiotherapy.

Longer term, expect a surge in patient complexity


Conditions that could require higher intensity care if people delay medical attention

Acute myocardial infarction Stroke Cancer Fractures and other

orthopaedic trauma

40%

Breast and pancreatic cancer treatment in Italy1,2

50-75% 24%

New pathology appointments made in Australia

March 15 April 15

Bypass and stent operations in Canada

Decreases in routine checks and procedures across regions

March 15 Present March April

Source: L Tondo, “Life ‘hanging by a thread’ for Italian cancer patients”, Guardian, April 7, 2020; M Cunningham, “Critically ill patients risk their lives to avoid hospital visits”, The Sunday Morning Herald, April 13, 2020; T Blackwell, “Surgery for cancer patients and others cancelled as hospitals brace for possible COVID-19 wave”, National Post, March 2018, 2020.




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Sources: Abelson R, “Doctors and Patients Turn to Telemedicine in the Coronavirus Outbreak,” The New York Times, March 2020; CipherHealth, “Using Proactive Outreach with Automated Coronavirus Screening to Minimize Community Risk of Exposure,” March 2020.

Use telehealth as default for all scheduled, routine visitsSystems getting ahead of complexity crunch with telehealth

Intermountain Healthcare• Expanding telehealth to home

health care for patients with chronic illnesses

• Patients take blood pressure or blood sugar readings at home and conduct virtual visits with a nurse

UCSF Medical Center2

• Automated telephone outreach system screens patients with upcoming appointments for COVID-19 symptoms

• Potentially-infected patients are connected with a virtual care team for triage instead of in-person visit

NYU Langone Health1

• Patients with minor medical conditions directed to a virtual urgent care platform

• Patients with existing medical conditions asked to conduct visits virtually

• Self-quarantined providers able to treat patients virtually

Three approaches to ramp up telehealth capabilities

1. New York University Langone Health.2. University of California, San Francisco Medical Center.




https://www.nytimes.com/2020/03/11/health/telemedicine-coronavirus.html

https://cipherhealth.com/using-patient-engagement-to-address-concern-over-the-coronavirus/


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1. National Health Service, England.Source: J Illman, “Coronavirus response could create ‘very serious unintended consequences’”, HSJ, 5 April 2020; S Marsh, “UK Government campaign will urge seriously ill not to avoid hospitals,” The Guardian, 13 April 2020.

NHS already seeking to mitigate unintended consequences


NHS England identifying at-risk groups and building intervention plans before complexity surge

Data shows significant drops in ED attendances, indicating people with serious health problems are avoiding care

NHSE1 established group to identify non-COVID-19 patients at risk of significant harm or death due to missed care

Goal to understand the scale of the problem, identify key patient groups, and plan appropriate interventions

The government is now planning a major public awareness campaign to stress that the NHS is still there for those who need it. The advertising agency Saatchi & Saatchi is understood to be working on the campaign without payment and it is expected to be launched in the next few weeks.”

The Guardian



https://www.hsj.co.uk/policy-and-regulation/coronavirus-response-could-create-very-serious-unintended-consequences/7027321.article

https://www.theguardian.com/society/2020/apr/13/government-campaign-will-urge-seriously-ill-not-to-avoid-hospitals


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Many providers will be constrained in ability to identify, serve all backlogged casesHow big is the pent up demand?


When do we reopen this service?

How many patients leave the queue?

What is our post-COVID capacity for this service?

How is post-COVID demand for this service different?

• Safety• Legal restrictions• PR concerns• Financial pressure

Longer shutdowns mean a larger backlog of unserved demand and more latent disease left to uncover

For any service, identifying and serving deferred demand depends on a four-part analysis:

More movement to other providers makes it easier to clear backlog, but means clinical history/data becomes split across geography

Productivity will be far lower than pre-COVID levels due to increased hygiene and PPE protocols, meaning staff pay will decrease per case

Lower new demand would make it easier to clear backlog, but difficult or impossible to sustain pre-COVID volumes

• Self-resolving issues• Care plan changes• Patients visiting other

providers that reopen earlier

• OR capacity• Staff, especially

specialised surgeons• PPE supply• New sanitation protocols

• Lingering fears of visiting health care facilities (-)

• Economic stress (-)• Poorly managed conditions (+)• Durable shifts in modality (e.g.,

telemedicine) (+/-)

Implications




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Your top resources for COVID-19 readiness


To access the top COVID-19 resources, visit advisory.com/covid-19

WHO Guidelines Compiles evidence-based information on hospital and personnel preparedness, COVID-19 infection control recommendations, clinical guidelines, and case trackers

Coronavirus scenario planning Explores ten situations hospital leaders should prepare for and helps hospital leadership teams pressure test the comprehensiveness of their preparedness planning efforts and check for blind spots

Managing clinical capacity Examines best practices for creating flexible nursing capacity, maximising hospital throughput in times of high demand, increasing access channels, deploying telehealth capabilities, and engaging clinicians as they deal with intense workloads

How COVID-19 is transforming telehealth—now and in the future Explores how telehealth is being deployed against COVID-19 and essential next steps for telehealth implementation



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Weekly Global COVID-19 Update: Part 2

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