Navigating Healthcare Now: COVID-19 Edition

Welcome, to DispatchHealth Monthly Webinar Series: Navigating Healthcare Now: the COVID Edition. This session will be recorded. I am Melanie Plaksin, our vice-president of market growth at DispatchHealth and will be facilitating today’s discussion.

I am joined by Dr. Stefen Ammon, board-certified emergency medicine physician and medical director at DispatchHealth. He is a contributing member of the DispatchHealth COVID-19 Task Force designed to keep patients and providers safe through education and the development of safety and treatment protocols.

Before we begin, a few reminders. We will ask that you please keep yourself muted during the presentation. We will open the call for a facilitated Q and A at the end of the session. And you are welcome to share your thoughts and questions and chat throughout the course of the presentation.

So, without further ado, let’s begin. And if we can go forward a few slides. Before I hand the mic over to Dr. Ammon, I will start today’s session with a reminder on DispatchHealth. We provide urgent medical care in the comfort of home or place of need. This eliminates any need for unnecessary trips to the ER, which is often uncomfortable, expensive, and can cause unnecessary exposure to other illness.

Activating DispatchHealth clinical team is easy. You can request care by calling through our mobile app or online. Our trained medical team will conduct a brief risk assessment to ensure it is safe for the patient to be cared for by our DispatchHealth clinical team.

And Dr. Ammon if you can forward one slide. Once we deem it is appropriate, we send a trained nurse practitioner or physician assistant along with a DispatchHealth medical technician (DHMT) directly to your community or home. They are supported virtually by an ER attending physician. Our patients receive care right at their bedside, on their couch, or at their kitchen table.

Post-care, we communicate with the – post-care we communicate across the continuum including with the patient’s PCP to ensure we are talking the patient back in with their care team. We also bill insurance directly at a fraction of the cost of an ER, call-in prescriptions, all while our patients focus on resting and getting better faster. Our teams are available for extended hours, seven days a week including holidays.

All right. So, now for the reason you joined, I will let Dr. Ammon take it from here.

Well, I wanted to speak to you a little bit today about the COVID-19 pandemic, specifically, as it relates to keeping yourself, your family, loved ones, as well as your staff, and older adults safe. And I also wanted to touch upon this psychological impact associated with the pandemic as well as some different strategies to manage that psychological impact with care providers, staff, and older adults.

I would be remiss to provide this information without at least providing a little bit of background regarding SARS-CoV-2 or COVID-19 only because this informs many of our strategies in terms of how to best keep both ourselves and our patients and residents safe.

So, just a little bit of background as all of you are likely aware, in early late December, early January 2020, Chinese authorities identified a cluster of atypical pneumonia cases in Wuhan, China. Ultimately, this was all attributed to a novel or new coronavirus that was named SARS-CoV-2 as in – or excuse me, Severe Acute Respiratory Syndrome to Coronavirus No. 2.

This was a novel virus. The importance of novel, of course, meaning that it is new or never before seen by the human immune system, which is why it has spread as aggressively as it has, as there was no pre-existing immunity. It is a coronavirus.

Coronavirus is a large family of viruses that typically cause mild URI-type symptoms or upper respiratory infection type symptoms. There are literally hundreds of known coronavirus. They typically infect animals, such as pigs, camels, bats, dogs. And we know of seven versions that have jumped to the human species. Three of these are known to cause severe respiratory and sometimes fatal respiratory infections. That includes SARS or Severe Acute Respiratory Syndrome, No. 1, which started almost 20 years ago was first identified about 20 years ago. MERS or Middle Eastern Respiratory Syndrome, which was identified about 10 years ago. And then, of course, SARS-CoV-2.

To give you an idea of mortality and comparing these entities, so, SARS-CoV-2, it is still estimated, of course, but we figure has about a two percent mortality rate for all comers. So, in other words of all, the people that acquire SARS-CoV-2 and develop COVID-19, which is a clinical illness caused by SARS-CoV-2, about two percent of those will die. And at this point, we have had nearly 800,000 – more than 800,000 deaths attributable to SARS-CoV-2 internationally. Compare this to seasonal flu, which has a mortality of around .1 percent and takes about 300 to 600,000 lives per year.

Further compared to pandemic influenza, you probably heard a lot of talk about the 1918 Spanish flu, that has a mortality that really hovers around what we see in terms of SARS-CoV-2. SARS, itself, the first SARS and MERS, actually were much more fatal when contracted. So, 15 and 30%, respectively, but the spread was much less significant. And each of those was responsible for less than a thousand deaths. So, definitely not on scale with what we are seeing in terms of SARS-CoV-2.

As far as the current state in the world, so as of earlier this week SARS-CoV-2 or COVID-19 has been identified or confirmed in more than 23 million cases worldwide resulting in more than 800,000 deaths. If we look at the United States experience itself, this is 5.5 million cases with nearly 180,000 deaths. The map shows the distribution. And it is ubiquitous throughout the United States though, obviously, there are areas where is more severe and areas where it is much less severe. And we see that particularly in areas that are not very densely populated like Wyoming and Alaska versus California, Texas, and Florida where there is more significant population density and a much higher burden of disease.

So, as far as COVID-19 transmission, what do we know. Well, there have been a number of things that have changed as far as what we understand about the virus since it first started and came to our attention. But principally, we feel that the virus is typically spread through respiratory droplets. These are large droplets that you produce when you cough, sneeze, sing, when you speak loudly. And these large particles then are so large that they are only suspended in the air for minutes. They fall to the ground typically within six feet.

And so, that is the reasoning behind the rationale for requiring or requesting that folks wear masks and participate in social distancing. The masking obviously provides source control from those who maybe expelling virus that are either symptomatic or asymptomatic. And social distancing then keeps us out of harm’s way in terms of where those drops then fall.

In addition, people can also be infected not only from these viral droplets that are circulating but should someone who is sick cough into their hand. And then, subsequently touch another item or shake your hand, that is the other way that the virus is oftentimes contracted. So, you shake the hand of someone and then later on rub your eye or touch a mucous membrane and subsequently contract the virus. And so, that is the reasoning for the rationale that we suggest washing hands, so as to remove the virus from the hands.

Finally, we know that the infection can also be transmitted via fomites which are inanimate objects. So, you are sick, you cough, you touch a doorknob. Somebody else comes and touches a doorknob or touches a desk or touches something that you had handled and then again touches themselves. And that can also cause spreading the infection which is why we recommend disinfection as one of the hallmarks of protecting from contracting the virus.

There has also been some discussion about aerosolization of the virus. Aerosolized particles are just much smaller than respiratory droplets. And the importance of that is that they suspend in the air for up to three hours. They are much smaller. And so, it changes things pretty significantly in terms of how we would protect ourselves from the virus. But suffice it to say, based on our experiences thus far over the last number of months, the infection really seems to be spread primarily in respiratory droplets.

We also find the virus in feces, urine, and blood, but at this point transmission seems uncertain. So, again, the actions to reduce COVID-19 are going to – you are going to see this recurrent throughout the presentation is really the W’s, wearing masks, washing your hands, and watching your distance.

So, in terms of just a few words about mask-wearing, obviously, this has been a significant point of interest and also a significant point of controversy since the onset of the pandemic. Mostly because I think, particularly in the United States, this has been elevated to the level of a political issue, where we are infringing upon individual’s rights to make decisions and counter-balancing that with the overall safety of society.

So, what is the evidence to suggest that mask-wearing is important. And there is good evidence. There are significant number of studies available to review. I was just going to highlight three real quickly. And again, I think my greatest point here is to make sure that you can use this information to help to speak with your staff or family members, co-workers, neighbors who may have concerns or questions about the efficacy of mask-wearing.

So, the first study I have highlighted here is a large-scale study where they looked at 198 countries and really looked to see what contributed to mortality in these countries as it related to deaths from coronavirus. And what they found was when they looked at all of these comorbid conditions or social issues related to how tightly packed people were living or adoration, infection, lockdowns, mask-wearing, what they found was that of all of the things that you can modify in your environment, mask-wearing was hands-down the most valuable way to prevent infection.

And so, if you look at the countries where they were not wearing masks the per-capita-weekly mortality rate increased at a rate of 55%. When you compare that to countries where they were wearing masks effectively, greater than 80% of the time, that drops down to seven percent in terms of weekly-mortality rate of increase. So, pretty significant and compelling argument in terms of the effect of mask from that study.

In addition, we can look at the Hong Kong experience. As you know, Hong Kong is a small area that is just off the coast of China. It is one of the most densely populated places in the world and has a population of 7.5 million people. If any country or if any area would have been significantly affected by COVID-19, you would think it would have been Hong Kong just given the proximity to Wuhan where the virus was first identified. And instead, what we see is that in Hong Kong where there is significant mask-wearing compliance, largely due to history, and cultural norms, where 97% of the population was wearing a mask, that as of this last week, they have had a total of 4,600 cases with 76 deaths.

Compare that to just one state in the United States, trying to find one that matches in terms of population density, like Arizona, which has 7.2 million residents, where there were 198,000 and 4,700 deaths. So, again, pretty significant difference in terms of the way that infection spread within society.

Last example is a simple one that was put out by the CDC that highlights two hairstylist living in Missouri who were COVID positive, who then took care of almost 140 clients while they were sick. During that time, they wore masks and 98% of the clients wore masks and there were no documented cases of infection. A large portion of those patients were also tested and demonstrated no evidence of contracting virus. So, again, just more evidence to suggest the importance of mask-wearing.

So, returning to COVID-19, the infection and symptom timing, these are some of the aspects of COVID-19 that have been particularly difficult and challenging to manage. The first being that infected patients will shed virus for one to three days before their symptoms start. And the point here is obviously that people are spreading virus before they even know they are sick. And so, it is very important that everyone wear masks and participating in social distancing even when they do not have symptoms. Once they develop symptoms, it is too late, the cats out of the bag, and you have already exposed everyone around you.

In addition, the incubation period associated with COVID-19, that is the time from exposure to symptoms, is typically about five days and can be as long as 14 days, which makes it very difficult, again, to identify who is sick – who has become sick and who they may have exposed if their exposure may have been up to 14 days before they actually developed symptoms. And so, it is important to recognize that symptoms do not start right away with this illness.

In addition, we detect viable virus up to nine days after the symptom onset in patients, which means people can infect others for a very prolonged period of time. And we see that becoming even more significant in patients who are severely ill or immunocompromised. They may shed virus for even longer. So, again, the importance here is that people can infect others for a long time. And so, we need to be vigilant in those who have tested positive and have symptoms.

And finally it is important to recognize that those who do develop critical illness, which is about five percent of the time, typically do so around Day 10 of the illness, which is somewhat atypical. So, it is easy to be fooled that people are on the mend and they are getting better when all of a sudden in the latter stages of illness, they actually become quite critically ill, which is important for us when we are taking care of other patients or helping to guide their care.

So, in terms of symptoms, the first thing to notice in terms of symptoms is that we think around 16 to 20 percent of patients are actually asymptomatic. So, that is they have the virus and they actually never have any symptoms at all. Again, which makes it particularly difficult to combat shedding the virus or prevent spreading the virus in those who may not have symptoms.

In those who do develop symptoms, we see fever is the most common, up to 85% of the time, but it should be noted that early on that is not always the case. And so, I know a lot of us are performing temperature screening, which is important, but it is also important to recognize that that does not necessarily completely keep us safe by just honing in on fever. So, it is important to also assess for other symptoms.

The other symptoms include cough, hyposmia or anosmia, which is lack of smell or diminished smell, we see in a relatively significant proportion of patients up to 40%. And interestingly, those patients can have those symptoms for months despite having recovered from the virus. We also see shortness of breath relatively commonly. And in addition, we see typical viral symptoms of body aches, sore throat, headache, nausea, vomiting, and diarrhea also seen in relatively significant proportion of patients.

As I mentioned nearly 80% of patients who are symptomatic will suffer primarily mild illness. So, these are the patients who do not need to go to the hospital or typically are not hospitalized. And conversely about 5% of those who contract the illness really become critically ill to the point where they require hospitalization and then ICU, often times are intubated on a ventilator, and are at risk of dying from respiratory failure or severe sepsis.

Last point to mention is that in recognizing older adults in particular, it is important to recognize that in those patients over 65, the baseline temperature is lower. So, sometimes a couple of readings over 99 can actually be indicative of infection and fever. So, it is just important to be particularly vigilant in that patient population.

A quick word in terms of testing which I know is a point of significant confusion often times. So, there are a number of different tests that are now becoming available. At the start of the virus, we really had primarily molecular testing the form of a RT-PCR test. And this would tell you if you are acutely ill. So, this is the test you perform to find out if you are infected right now with COVID-19.

These tests assess for the presence of viral genetic material, so RNA and are often times available with one two days. We know that the early onset of the pandemic that oftentimes these tests were taking greater than a week simply because of the volume. And fortunately, there are some newer tests that are much more rapid that are becoming available. It will help us as we move forward.

The benefit of the PCR is that it has a high sensitivity, so it works relatively well to identify those who are asymptomatic and minimally or mildly symptomatic. The downside is that if you do have a positive PCR, it does not necessarily tell you if you have an active-alive infection or if perhaps you have recovered from an infection and may be shedding what we describe as dead virus.

And so, we have a number of case reports in which patients will test positive for 12 weeks by PCR testing after they have been sick. And at that point, are not really shedding live virus, they are shedding dead virus. And obviously, the difference there being whether or not they are going to infect other people.

In terms of other particular tests or options for testing that would identify acute infection, there is antigen testing. This has become much more available to us in the very recent past with point-of-care testing and tests that are available on scene. This is looking for the presence of a protein on the surface of a virus. The benefit of this test is it is very rapid. It is often times available – the results are available within 15 minutes.

The downside of antigen testing that everyone here should recognize is that it has poor sensitivity in asymptomatic or mildly symptomatic patients. So, in other words, even though this test is readily available and you get the results back immediately, it is not the best test to go through if you have a communal living center and identify whether or not people are carrying the virus because it is just does not have enough sensitivity in that asymptomatic patient group.

Finally, there is also serological or antibody tests that are available. These do not tell you about active infection but tell you that you have been infected in the past. There is a lot of controversy surrounding these tests, principally, because the initial versions of the test it was felt may not have been specific for SARS-CoV-2 and may have demonstrated antibodies development to other coronaviruses and as I mentioned there are a number that circulate in society.

In addition, there have been a number of studies that show that these antibodies oftentimes disappear within a few weeks. And so, you may not detect that in a person depending on when you are testing them. And it is also unclear as to what the significance is as to whether or not antibodies really do provide protection. We suspect they do. There was just a story on the New York Times, I believe yesterday, the day before about the first documented case of an individual where they believe that this individual actually contracted the virus, got better, and then contracted another version, raising concern about whether or not antibodies and our immune system provide protection from subsequent infection.

And so, there is, again, just a lot of controversy around this. So, the take home here is to realize that no test is perfect, that clinical suspicion trumps any test results. So, if you have a person under your care in an assisted-living center who has had a positive exposure to COVID-19 and that person develops fever and cough and body aches and their COVID test comes back negative, it does not matter. You should treat them as if they are positive. And so, we really want to err on the side of caution because the test just are not sensitive enough for us to say definitively that this patient does not have COVID-19.

Finally, the last thing to mention is that the CDC does not recommend a test-of-cure strategy. So, in other words a lot of people are in the virus or advocating that after a person had an infection that you should test them to prove that they cleared the infection. And for the reasons I have mentioned, particularly related to the PCR test, where people will test positive for a number of weeks after they have actually cleared the infection, this is no longer advocated. What we advocate is a symptom-based strategy which recommends that patients are cleared after 10 days since the onset of symptoms plus they have been afebrile for 24 hours, not on antipyretics, and they have improving symptoms.

So, how do we protect anyone, ourselves, our family members, our staff, older adults from the virus. And I think the CDC provides some great guiding principles here. And their takeaway message is the more people you interact with, the more closely you interact with them, and the longer of that interaction, the higher your risk of getting and spreading COVID-19. There is absolutely no way to have zero risk when interacting with others.

So, it is incredibly important that we try to mitigate these risks by avoiding crowded situations and close physical contact and enclosed spaces, where the viral burden will be greater if there is someone that is sick. And we really try to limit exposure to what is truly necessary. In addition, as I mentioned before, we really want to focus in on those W’s, wearing a mask, washing your hands, and watching your distance, as well as cleaning and disinfecting any surfaces that might harbor the virus.

So, what about older adults? Well, a few things that we know about this virus from the onset and that is that patients who have multiple comorbidities which includes a lot of our older patients, do not do well with COVID-19. They have a much higher risk of hospitalization and death.

And so, what this graph shows is basically that if you have comorbidities, asthma, obesity, diabetes, high blood pressure, kidney disease, that your risk of getting really sick should you contract the virus, becomes much more significant. And further, that if you have more than one condition, so you have two or three comorbid conditions, that that risk increases even yet again.

Further, when we look at age as the risk factor, we know that that has even a greater risk associated with hospitalization and death should that individual contract COVID-19. In fact, the United States, we know that 8 out of every 10 COVID deaths that we have reported have been in individuals over the age of 65.

So, if you look at this graph it is actually very impressive. If we use 18 to 29-year-olds as our comparison group, you can see that once you turn 65 years of age, that your rate of hospitalization goes to five times higher should you get sick and your rate of death goes to 90 times higher. Those numbers become multiplied the further you go such that when you are over 85 years of age, your risk of death should you contract coronavirus is 630 times higher than if you were 18 to 29 years of age. So, that really just demonstrates how important it is to make sure that we protect our older adults.

So, what are the strategies we can use to keep these individuals safe? Well, it is a lot of things we have talked about. And I apologize for being repetitive, but they really are the cornerstones of being safe, the W’s, wearing your mask, wash your hands, watching your distance, as well as cleaning and disinfecting.
We also know that we can reduce exposure and by reducing exposure then we do not have to worry about all of these actions to reduce infection. And so, there are a number of ways it had become evident over the last few months. We have been very thoughtful about ways to provide virtual care to patients. That individuals can seek groceries from mobile sources. That there is mail delivery. That they use a number of different mechanisms really to try and prevent any in-person exposures or contact. And then, again, just reiterating that when we do interact that we recognize that we take those precautions that we have mentioned.

The other two really important pieces that I want to mention in older adults is one, to remember that we need to continue to care for their chronic health conditions, immunizations, refilling medication prescriptions, making sure that they are following up with their healthcare providers. This should not fall to the wayside and this has a great impact on long-term health. And so, we need to make sure we encourage this vulnerable population to continue to take care of themselves and their chronic medical conditions.

And the last issue I want to hammer home is that we need to take a very rational approach to acute medical conditions. And what I mean by that is both while practicing in emergency medicine as well as, well, serving as a medical director with DispatchHealth, I have seen numerous examples and situations in which an elderly person is suffering from an acutely life-threatening condition. And I am talking heart attacks and strokes, and these are situations in which these individuals are adamant about not going to the ER and not going to the hospital.

And the reality is that for someone who is suffering an acute heart attack or a stroke, their morbidity and mortality risk is much higher from the acute medical condition than the theoretical risk of them conducting or contracting COVID-19. And so, we really need to take a rational approach when it is appropriate to seek medical care for these patients.

What about those who are living in communal living assisted living or even nursing home residents? I would point again towards the CDC recommendations. The more you interact, the more closely in you interact, the longer that interaction, the higher your risk of getting and spreading COVID-19. This is particularly important again, where we have congregate living right, where people are exposed to respiratory pathogens and multi-drug resistant organisms. We know from previous experience that more than 40% of the COVID-19 U.S. deaths have been tied to nursing home residents. So, obviously, a very vulnerable population for us.

And so, what are the strategies we can use in these communal living situations to help to protect patients. Well, there is a couple ideas. And many of these come from the CDC. And I have referenced that site here on this slide. But they advocate identifying if you have the option somebody on site who is a local infection specialist.

This does not have to be a physician. It does not have to be someone has their master’s in public health. This really just needs to be somebody who can keep their eye on the news, can continue to monitor the CDC website, and can help to develop protocols, education, and surveillance within the facility. And really can be an internal resource or at least, know where to find answers for folks better that are on staff.

In addition, it is recommended that you follow the CMS guidelines for criteria regarding reopening. I have cited that website here on this slide, but it is a great website, very informative that gives a lot of guidance regarding how strict or loose you can be in terms of intermingling and opening up, and really is predicated on how recently your last infection was within your facility, and helps to really guide you in terms of what measures need to be taken to keep communal living members safe.

We also want to continue to employ our full infection control. So, caregivers wear masks at all times for the reasons I have enumerated. Residents wear masks when in communal settings if possible, that you restrict group activities appropriately based on disease burden, that you perform regular screening of both your residents and care providers. And as I mentioned that includes temperature and symptoms screening, which again are important but should not hold all the weight. It really needs to be part of a strategy to keep everyone safe as well as regular testing, which has been advocated in a number of sources to make sure that folks stay safe in this setting.

Finally, in terms of visitors, we want to restrict and advocate virtual visitation whenever possible. We want to screen visitors when they show up. We want to facilitate social distancing by having folks meet outside or out of doors when possible, separating chairs by six feet just to help to guide people along to make sure that we keep them safe and keep all of our other members safe.

We want to cohort residents and caregivers. So, if you do have folks who are sick, trying to identify distinct caregivers that will take care of them, so as to prevent any cross-contamination is very helpful. And really following quarantine principles following any exposure is wise as well.

In addition, interestingly, there are a few states in the country where they have deployed what are called strike teams, which is an interesting concept borrowed from emergency-disaster-response models. So, basically, they have used this in Texas, Massachusetts, New Jersey, Ohio, Wisconsin, and Tennessee to name a few. And what has happened in these states is when they do identify a communal living facility that has been overburdened or overrun, they can send in a rescue team, a strike team, that can provide additional resources additional providers, ranging from emergency staff to social support staff, really to help to weather these difficult situations.

What about keeping staff safe? So, keeping caregivers or even office staff. How do we keep everyone stays safe that works in our facilities and our institutions? Well, it is much of the same thing that I have mentioned before. And I apologize for harping on the washing, watching your distance, and wearing a mask. But in addition, we want to continue to reduce exposures, keep exposures to only those that are critical and absolutely necessary.

When we are in a situation where we are providing healthcare to patients, we want to make sure that we employ full PPE. So, per the CDC, that includes a simple surgical mask, glasses, and gloves for every exposure. And we can see from this graph here that if we do those things, even if we are taking care of somebody who has full-blown COVID, that we are safe. We are safe to continue to care for other patients and we should feel safe as care providers. And so, it is very important to focus in on PPE-use in that setting.

In addition, one of the other big, important factors to make sure we are keeping staff safe from staff. As I mentioned, oftentimes people are sick and do not know it or they are pre-symptomatic, or they are asymptomatic. And so, they can in turn infect additional staff members that then put the entire facility at risk. And so, we really want to make sure that staff are wearing masks when they are interacting with staff. And really, that mask should stay on the entire day when you are in the facility.
When I am working, my mask is on from the moment I walk through the doors until the time that I leave. Finally, in terms of cohorting, same thing. We really want to limit the number of staff that are contacting patients. And that not only keeps patients safe, but limits exposures to staff as well.

So, what about the psychological impact of COVID-19? We are well aware the public health emergencies affect the health, safety, and well-being of individuals and communities. And our previous experience has really been with natural and human-caused disasters. And the thing that makes these disasters a little different than what we are going through right now is natural disasters, so tornadoes or hurricanes or fires and human-caused disasters, think of 911.

These are distinct events and though the effects of these events go on for a long time, the event itself, the the immediate danger is associated with a distinct event versus with this pandemic that things are just going on and on. And I think that that definitely has a significant psychological impact for all of us.

In addition, there are a number of stressors we experience related to the pandemic including uncertainty and changing information. I know that as a member of the COVID task force, I literally have to watch the news daily because things change all the time. And that uncertainty and that constant change really does affect, I think, people’s comfort level with the pandemic knowing how to stay safe and how to keep their loved ones safe.

In addition, there have been conflicting messages from different authorities within our government and media, which has led to some confusion and has led to stress associated to the pandemic. Resource shortages including PPE for healthcare providers have been a large part of stress for us, as well as unfamiliar public health measures, like I mentioned, that really pit personal freedoms against public health, thinking of mask wearing in this instance.

And then, finally there is the very real large and growing financial losses that so many of us have experienced, unemployment, food insecurity, looming evictions when folks cannot make rent really has added significantly to pandemic, a psychological burden.

So, when we look at how widespread this psychological burden is within the United States, we can look to a study performed by the Kaiser Family Foundation, believe this was performed earlier on in the pandemic. But even at that stage, we recognize that more than half of Americans felt their mental health was negatively impacted by the pandemic. A third describe difficulty sleeping, 12% describe increased alcohol consumption, substance abuse, or worsening health conditions. And this was manifest by anxiety, depression, insomnia, fear, boredom, and all number of manifestations of psychiatric illness.

And so, what can we do for these individuals? And what about specific segments of our population? So, again going back to the older adults, what are the things that they are struggling with the most right now? And I think all of you on this call probably know this far better than I do.

But two of the things I think that are burdening this population great greatly is anxiety and loneliness. Anxiety being a product of uncertainty, and a lack of clarity of control. Am I going to get sick? Is my loved one going to sick? And this becomes manifest by sleeplessness, unending worry, and an obsessive unhealthy interest in the pandemic. These are the folks who are watching news incessantly, reading everything that is available, and really cannot allow themselves to rest or get toward any other aspect of normalcy in terms of living their daily lives.

Also loneliness, obviously, is of significant concern for older adults. The social distancing associated with our recommendations leads to social isolation. And in some instances, loneliness, which is that subjective sense of feeling disconnected. We are reminded from Lisbeth Nielsen from the National Institute of Aging that we are social creatures and part of what brings meaning to our life is to maintain and foster these social connections.

And so, it is very important that we try to do so. How is loneliness manifested in this population? It is oftentimes found by a change in routine and self-care, not wanting to get out of bed, and anhedonia, which is a loss of pleasure in anything, and sometimes maladaptive behavior such as drinking.

So, what are the strategies we can deploy in this setting? Well, obviously awareness is key, education is very important, knowledge is power. And so, we want to make sure that we continue to educate everyone, but at the same time you want to be mindful about watching, reading, and listening to news excessively, which can cause significant anxiety and worry.

We want to add structure to the day and establish routines, provide exercise, allow individuals to get enough sleep, and continue to allow them to connect with others. Fortunately, given the date that we live and the world in which we live, we have the ability to connect with others virtually. And so, we really want to redefine social connection, emphasizing quality over quantity, and allow our older adults to continue to meet with family members and loved ones via different platforms than what we have done traditionally.

Finally, what about caregiver stress due to COVID-19? Well, some of the specific issues associated with caregiver psychological stress has to do with the risk of exposure to self and loved ones, which is very real and is part of our daily experience as we care for residents and patients. The constantly changing information and lack of clarity is cause significant stress as has PPE shortage, which I know that we have all dealt with.

Long hours with mental resources has contributed as our caregivers or additional members of our staff have gotten sick. And that work burden has been shifted to other individuals within the organization, has been a significant point of stress. And then, the moral injury to associate with it inadequate resources and really being focused with having to care for a large number of patients without enough resources, which really puts us in a situation where we have to make difficult decisions.

So, what are the things we can do for caregivers to help them with the stress of COVID-19? We can make sure that we continue to meet our basic needs through eating healthy, regular sleep, taking breaks. We want to stay connected with our loved ones and with our colleagues. We want to stay active.

We want to stay informed but limit excessive exposure to media as we have mentioned, embracing different stress management techniques, including yoga, mindfulness, meditation, and really being self-aware, monitoring yourself for depression, anxiety, sleep disturbance, intrusive memories, and hopelessness, so that if we are feeling overwhelmed that we can reach out to innumerable resources that might be available to help us to weather the storm.

And finally, I think one of the most important things that we can do as leaders for caregivers and staff within our organizations is to honor our service, to celebrate the noble calling, to remember that it is very important work that we do when we take care of people, when we help people, when we serve others. And just realizing that that is important work and that oftentimes that is what we will propel us forward during these difficult times.

Finally, looking forward, just a few last points. When will this all end? Only time will tell. I wish I could tell you definitively. It may be that COVID just becomes part of our typical seasonal human landscape. This is going to be particularly difficult as we enter flu season, where you are going to have great difficulty separating one from the other. So, it is going to be important to maintain vigilance and remember that the rate of COVID-19 co-infection with other illnesses including influences about 10 to 20%.

We know that vaccines are on the horizon. There are eight entering Phase 3 trials. These are looking for greater than 50% efficacy, but at best, a guess, we are looking at the first of the year to deploy those so. So, there is more to come and hopefully we will get there soon. So, that is that.

Great. Thank you, Dr. Ammon. At this point, we will open the floor for a Q and A session. You are welcome to submit your questions through chat. You are also welcome to come off mute and ask a question directly to Dr. Ammon.

While we are waiting for questions to come in there is one that was sent to me directly. Are there any known long-term effects?

[Crosstalk] Yes. Sure, so, what we do know is – and we have seen in certain individuals, the virus has a predilection for the lungs. And so, what we have seen is that a large number of people, the way that this manifests is with a pulmonary or lung infection. And so, it is not uncommon for people to have a very typical finding on their x-ray or CAT scan of pneumonia type finding in their lower lungs on both sides. And in some instances, this is causing permanent damage.

And so, for certain individuals who have severe disease, they can have long-term pulmonary effects, a loss of pulmonary function associated with the infection. In addition, as I mentioned the hyposmia and anosmia individuals who have lost their sense of smell or have diminished sense of smell, there are a large number of those folks where that goes on for months and months. And we do not know if it is going to come back at this point, which obviously, is a significant effect for quality of life really.

And then independent of that, the last thing to mention is that we do know that COVID-19 acute infection can be associated with an increased risk for vascular disorders. So, we see an increased risk of heart attack, stroke, and blood clots in the lungs associated with an acute infection. And obviously, if you were to suffer any of those events, there would be long-term side effects associated with each of those instances for a person.

So, hopefully that answers your question.

Great. And it looks like there is a question from Tammy. Is there any way we can get a copy of the presentation?

Yes. We will be sending the recording of this session out to everyone who is on, so that you have access to it.

Another question that came into me is, do you have any proper hand-washing techniques that you recommend?

No, that is a great question. You know, I think, I do not know the answer to that. I do not know if there is been any definitive studies looking at that effect. It certainly is – it adds to the stress psychologically. As far as long-term health effects, it is interesting – and that you have had that response in terms of your lung function. And I can see that that would make sense, that somebody who has reactive airways or may have trouble with wearing a mask for a prolonged period of time.

I do know that there have been some effects related to the mask-wearing itself, wherein particular with the N95 masks, they are very tight, and they sit over your nasal bridge. And so, people will develop breakdown of the skin over their nose. But at this point in time, I am not aware of anything specifically related to continually wearing a mask.

And it is – it is difficult for an eight, 10, 12-hour shift to wear a mask non-stop is particularly challenging. I think of – at DispatchHealth, our policies is that folks wear masks throughout the day. And I think often of our providers in Arizona and Texas that are wearing these masks in 100 plus degree weather.

I think that is incredibly accurate. I think in the time that I have spent speaking to a few people who are in that situation, it is incredibly challenging. And you are exactly right. If you observe strict isolation precautions to keep people safe, the psychological impact is significant. At the same time, if you loosen up your restrictions, then then people at risk for getting sick and getting sick when you are over the age of 65 can be life-threatening in many instances.

So, I think you are exactly right. I applaud you, all of you for your work. I wish there were easier answers and there are not, at least, me, but yeah. No, I agree with you entirely. You are definitely between a rock and a hard place when it comes to trying to find the right thing to do for these folks.

Yeah, no, I think it is a great question. I think at this point as far as the point-of-care testing, there are a couple of tests that are available and that just become available recently. And I think it is just important to know what you are testing for.

So, going back to the antigen testing, which is a lot of the tests that are now becoming available for the rapid test. Again, those just are not sensitive enough to identify asymptomatic or mildly symptomatic patients. So, I would not advocate doing those tests as far as screening tests within a facility.

You really are looking more for molecular tests that would have the adequate sensitivity to rule out an occult infection in an asymptomatic patient or a very mild infection in a mildly symptomatic patient.

And when you look at the inserts from each of these companies that sell these antigen tests, each of them acknowledge that if your suspicion is high or that you have concern, that you need to do more definitive testing, which would be a PCR type test or a molecular test.

That is a great question. And there is some guidance from the CDC about this. And most of them talk about a 10 to 14-day time from the positive test that you wait until they return to work. It is a challenge, again, because some folks will continue to shed bits of virus and will continue to test positive. The one thing you do have to be mindful of, and I touched on this a little bit is that if they have – if they were severely – so, if it was somebody that is say immunocompromised and had infection, that oftentimes they can shed for like 20 days for even a prolonged period of time, which obviously would put other individuals at risk.

And so, you need to have a little bit of clinical context as far as knowing the source. But yeah. But the CDC is pretty clear and provides good guidance around waiting 10 to 14 days from that positive test. And then, allowing that person to return to full activity.

Obviously, I can understand concerns related to highly risky or at-risk population like in a senior living facility. So, you could always also ask the recommendations of a local infectious disease specialist about what they would do or if there is any other definitive testing they would perform.

Yeah, no, it is a great question. So, for whatever reason, we again see that it attaches to – the way the virus gets into cells is through what’s called the ace receptor, angiotensin-converting enzyme receptor. And so, wherever we see these receptors is where the virus tends to get in. And so, again, we see this primarily in the lungs. There is some of this in vasculature, so the blood vessels. And so, that is really where we see the majority of the damage being done.

There is also reports of infection causing direct effects on heart-muscle cells. And so, again, primarily pneumonia and lung infection and diminished lung function and then in the vasculature, that effects everywhere. So, I am just talking about blood vessels. So, stroke, heart attack, and blood clots. You will see in the lungs. You will see that occurring in patients who have acute infection. And then, beyond that, some local direct effects on the heart are known as well. And again, this is not in every case. These are just distinct cases, but these are all instances in which COVID is wreaking havoc in different body systems within a person.

Yeah, no, it is a great question. So, you are exactly right. What they did find was that they can find this virus in certain animals. And so, they have found it in domesticated dogs, cats, and minks. Apparently, they are like mink farms and that sort of thing in certain areas, I believe within China.

And so, we do know that they must be contracting that from people. What we do not know is we do not have any real great ideas as far as if people can contract it from the dog. And so, there is still a bit of a question there. I know also that there was – I think it was a local zoo or a zoo within the United States where it was tigers had contracted the virus, but for those of you have pet tigers at home. But suffice it to say, the best thing to do is to exercise caution. And it is probably not to share animals.

Again, this, I think, would be particularly challenging at some of the senior living facilities, where they have common animals and some of them use common animals and it is very soothing for residents. But yeah, but generally, the thought is that some of those animals can harbor the virus.

Okay. I do not see any other questions in chat. I might pause for just a quick moment and see if there are any questions that people want to unmute and ask.

Okay. If not, we are starting to approach the top of the hour. I would say, thank you, Dr. Ammon so much, for your time that you spent with us today.

We do have another question that is coming in.

Yeah, no, that is a great question. And I am very pertinent. And there has been a lot of discussion about this lately. So, hands down if you have access to a surgical mask, we know that that is more protective.

And so, when we think about masks, there is kind of two elements to the mask. There is source protection. So, that is if I am sick, it is keeping me from spreading the virus to others, that is source protection. And then, the ability to contract the virus.

And so, if we look at the masks, we know the N95s, these are the masks that have the greatest protection in terms of both contracting and spreading virus. Obviously, they can be a bear to wear. They have been hard to come by related to the pandemic. And sometimes, they are just not practical.

If we look at surgical masks versus cloth masks, what we know is that the layers within the surgical mask definitely provide more protection, both in terms of spreading and contracting the virus. But we do know also that cloth masks that they do provide some protection. So, I know there was one study where they looked at how far virus would spread in somebody who coughed who had nothing on. So, it is about 10 feet. If you put on a cloth mask that gets us down to within a few feet. And then, once we put on the regular surgical mask, a N95, you get into within inches of spreading that virus.

So, the point being there is benefit to the cloth masks, not enough benefit that healthcare providers should wear them. But they definitely do provide some protection. But between the cloth mask and a surgical mask, surgical masks definitely provides more protection in terms of both spreading and contracting the virus.

Yes. No, that is a great question. So, absolutely and thank you, for bringing that up and I should have mentioned it in the presentation. But all of those studies that talk about the efficacy of masks have to do with it being worn properly.

So, wearing your mask like a beard does nothing. Wearing a mask with your nose out, likewise, is defeating much of the purpose. So, it really needs to be fit over the nose and face. One of the downsides is some of the homemade masks and in particular, things like bandanas and the buffs that you wear is that without a good seal that you do have spread of – you have the possibility of spread of virus from around the mask.

So, definitely affects the overall efficacy. But exactly correct, for full efficacy, it really needs to be worn properly. And one of the things that is difficult for healthcare providers is that when you are wearing it all day, you are constantly playing with it, which does put you at risk for contaminating your mask, then contaminating your hand, then contaminating yourself, then contaminating someone else. So, it is really important in an ideal state when you put on that mask it stays on, you do not play with it, you do not touch it. And if you do need to adjust it, you put on gloves and adjust it, and then clean your hands.

It is a great question. So, like I said, more than a hundred in development, a large portion are undergoing the large-scale studies. They are going to decide what is effective by greater than 50% efficacy. So, if it protects you from 50% of the virus or in other words, if you get the vaccine and you are exposed to the virus, if it protects you more than half the time, then it is going to be deemed a success.

I think it is going to be in some respects kind of a race to see who gets there first. There are a number of different pieces as well associated with this. So, most likely, whatever vaccine comes out you will have to have a booster or subsequent vaccination following the first vaccination to achieve full efficacy.

I know that in China and Russia, both of them apparently have vaccines that they are working on preparing to deploy in October. So, I think they are a little bit ahead of us. There has been a lot of question about whether or not they have done their due diligence in terms of all of the necessary testing. I cannot speak to that. But yeah.

I think it is going to be to some degree, honestly, it is a bit of a race. And hopefully, we will have more data as things come out about which is most effective and importantly, which is associated with the best side effect profile and which is best tolerated.

Yeah. That is a great question. And recently, there was some more mention from the CDC about use of face shields. I think they are fantastic. They do not supplant the use of a mask. So, I would not get rid of my mask and in place of it, use a shield, but a shield is a great way to protect you from contracting virus.

One of the difficulties we have with this pandemic is prior to now, none of us would have reused a mask. We would have used a mask for a patient interaction and then you take it off or at best you would have one patient you would use that mask with and then you would take it off when you were not taking care of that specific patient.

And obviously, the challenges we have had with the supply chain had forced us to where we are really in an emergency situation and we are reusing masks throughout the day. So, one of the risks of wearing the mask throughout the day is that that masking can become contaminated. So, if you wear the mask, you take care of somebody who is coughing, then they can spoil your mask. So, I think a face shield is a great way to protect your PPE. It is PPE for your PPE and it is easily cleaned. So, I am a big advocate for those splash guards and splash masks.

That is great. Thank you, Dr. Ammon.

I will ask you to go to the next slide just as we come towards the top of the hour. We would like to invite you all to our next session of Navigating Healthcare Now. That that will be scheduled on Tuesday, September 22nd, that is 1:00 p.m. Eastern, 12 p.m. Central. And our topic will be Flu or COVID: Preparing for Flu Season During the Pandemic.

And if you go to our next slide, I just want to thank you all, so much for participating. We would love your […] – please share your thoughts in our post-webinar survey, including additional topics that you would like us to cover.

If you have interest in learning more or discussing how we can provide more value through our partnership with DispatchHealth, our local community and market leaders are happy to meet with you. We will be sending a recording of today’s session along with that survey.