April 15 COVID-19 Update – Pennsylvania American College of Physicians

April 15 Pennsylvania COVID-19 Update

On Tuesday the Department of Health reported that Pennsylvania had found another new 1,146 positive cases in the previous 24 hours, for a total of 25,345. The death total rose to 584 deaths, with 17 reported on Monday, all in adult patients. There were 108,286 negative tests in PA as of midnight Monday night.
The Department noted that of the positive cases, 1,250 cases have been in health care workers, an increase of 112 since Monday and another 1,869 of the positive cases facilities are in 232 of the state’s licensed long-term care facilities(up from the 215 facilities reported on Monday).
Tuesday at noon, approximately 2,306 COVID-19 patients were hospitalized, approximately 10% of those testing positive.  At that time, 674 were using ventilators or ECMO.  About 42% of beds, 37% of ICU beds are available, and 1499 of 4909 ventilators were in use (nearly 70% of ventilators were still available.) 
Of the patients who tested positive to date the age breakdown was unchanged from Saturday: less than 1% are aged 0-4; less than 1% are aged 5-12; 1% are aged 13-18; 7% are aged 19-24; 40% are aged 25-49; 29% are aged 50-64; and 22% are aged 65 or older. 
51% of the patients hospitalized are aged 65 or older, and 29% are aged 50-64.  19% are ages 25-49.  Most of the deaths have occurred in patients 65 or older. There have been no pediatric deaths to date.
Levine said data on race and other demographic information is missing on 60% of patients.  Today the DoH through the Health Action Network reminded providers and laboratories this information is mandatory.  Accuracy of information collected depends on the reporters and the information they put into the system.  She thanked providers and laboratories for their patient care, then asked them to provide best data possible. (See below)
Health Reminds Providers of Necessary Reporting for Testing Demographics
Tuesday afternoon, Dr. Levine noted that DoH has identified a large number of laboratory test results submitted without key variables including patient date of birth, address, and telephone number and other demographic information.  She said about 60% of the test reports were missing key information on race and ethnicity.  These demographics are essential for correct jurisdiction assignment and for the timely initiation of case investigations, particularly related to COVID-19 exposures:

  • Key demographic variables including patient date of birth, phone number, address, race, and ethnicity are frequently missing from laboratory submission forms and patient test results
  • These variables are essential for a complete and timely public health response to patients with COVID-19 and other reportable diseases
  • Providers are reminded that patient date of birth, address, telephone number, race, and ethnicity data fields should be included on all laboratory submission forms
  • Clinical laboratories are mandated to report the name, age, address, telephone number, and other information requested by the Department regarding the person from whom the specimen was obtained.

This information is necessary to understand public health disparities across the Commonwealth and to guide resource needs and allocation.
The Department said that if this information is not included on the laboratory submission/requisition form, the ordering facility should enter these demographic elements into PA-NEDSS as mandated under PA Code, Title 28, Chapter 27. Clinical laboratories are required to report the name, age, address, and telephone number from whom the specimen was obtained under PA Code, Title 28, Chapter 27: § 27.22 “Reporting of cases by clinical laboratories.”  However, they are unable to do this if they do not receive the information from the providers submitting specimens.
In addition, clinical laboratories reporting via ELR should report race data in PID10 and ethnicity data in PID-22 as per Health Level Seven (HL7) version 2.5.1 guidelines. Clinical laboratories using manual entry into PA-NEDSS should include this information in the appropriate short form sections.
The updated order from the Department of Health on inventory of PPE, equipment and certain pharmaceuticals in the Governor’s April 8 order requires compliance by  11:59 p.m. on April 16, 2020.  You can find all of the details online here.
The Order requires all health care providers and facilities, whether presently opened or closed, and including, without limitation, physician practices and dentists, to report their inventory.  The items required to be reported are categorized on the Inventory Portal and include the following:

  • PPE (gowns, gloves, face masks and shields);
  • Certain durable medical equipment (ventilators, anesthesia machines, unused vent circuits and ECMO machines); and
  • Certain pharmaceuticals that may aid in the support and treatment of individuals with COVID-19 
    • Various Paralytic agents
    • Injectable benzodiazepines
    • Opiates
    • Other anesthetics (viz., Etomidate, Ketamine, Propofol)
    • Respiratory treatment pharmaceuticals ( Albuterol MDI, Albuterol nebulized , Norepinephrine)
    • Azithromycin and hydroxychloroquine

ABIM Extends certifications through 2021
Richard J. Baron, MD, MACP, President and CEO of the American Board of Internal Medicine announced increases in flexibility to maintaining certification as a result of the COVID-19 pandemic.  ON the ABIM website, Barron said April 13, “Recognizing the unprecedented demands being placed on all of our board certified physicians, ABIM wants to be sure you are able to maintain your certification despite the stresses you are facing.  That’s why today I am sharing an important update with you: No one will lose certification if they aren’t able to complete a requirement this year.
Barron said that any physician who is currently certified and has a Maintenance of Certification (MOC) requirement due in 2020—including an assessment, point requirement or attestation—will now have until the end of 2021 to complete it. Physicians currently in their grace year will also be afforded an additional grace year in 2021.
He said that as of now, all fall 2020 MOC assessments will be offered as planned, so you can still take an exam this year if you’d like.  We are sending this message now so you can focus your time and attention where it is needed most: caring for your patients and your community.
Barron’s announcement concluded, “On behalf of ABIM, I want to personally thank you for all that you are doing for your patients during this time. If you are in a hotspot and treating patients suffering from COVID-19, my heart and my admiration go out to you. You are, every day, demonstrating the best of our profession. During this trying time please know the entire internal medicine community stands behind you and is here to support you however we can. Please stay safe.”
Concern Growing for Rural Hospitals
Reports are growing that rural hospitals are in danger of running out of money, as they’ve cut back with no elective surgeries have limited beds in use.  As the pandemic moves into rural Pennsylvania and the rest of the country, the fact that they were an oversight in the economic rescue package is causing genuine concern.  About one-third of rural hospitals and one-sixth of rural health clinics are owned by their county or municipality.
This is problematic in applying for stimulus loans, because “Government-owned hospitals and municipal owned entities” are not able to get the small-business loans that other small businesses are applying for. That’s cash relief that they say is really needed.
This hole in the stimulus was apparently unintentional, multiple Republican and Democratic congressional aides said. Congress or possibly the Trump administration would have had to create an exception to let municipal-owned entities receive federal small business loans
General Assembly – Economic Reopening, PHC4 in House
The State House of Representatives, Tuesday, after hours of debate, passed legislation (SB 613) that  by a 107-95 virtually party line vote, would create a way for businesses to reopen if they follow federal safety guidelines for dealing with the COVID-19 pandemic. 
PA-ACP has opposed legislation and amendments that would tie businesses to CDC and CISA recommendations from any specific date, as those recommendations and guidance are changing as more data and evidence is developed about the novel coronavirus.
The Senate returns to Harrisburg on Wednesday, to consider several of these bills and others relating to the budget.  Speaker Turzai said they House may be recalled “later this week.”
Senate Bill 613, approved 107-95, challenges the foundation of Gov. Tom Wolf’s executive order last month closing non-essential businesses due to the pandemic. All Democratic lawmakers voted against the bill and two Republican lawmakers joined them – State Reps. Tom Murt and Todd Stephens of Montgomery county crossing party lines,  
The bill requires the Governor to implement a plan for reopened businesses to mitigate the spread of the deadly virus that follows recommendations from the federal Centers for Disease Control and U.S. Cybersecurity and Infrastructure Security Agency.  SB613 now returns to the GOP-controlled Senate for concurrence. The Senate is scheduled to reconvene Wednesday to vote on SB613 and other COVID-19 related bills. 
When asked about the bills during a Tuesday afternoon conference call with reporters, Wolf said “the bills keep changing,” but “there are things that I don’t like about what I’ve seen right now.  If we don’t do this right, the economy will be in worse shape than it is now.”
Wolf declined twice to comment about specific bills, saying what was in them was in flux.
“I will reserve judgment until I see it,” Wolf said. He and legislative leaders spoke earlier in the day but had yet to reach agreement about elements of what he would support in the legislation.  “We’re all trying to do the same thing, but we have different ideas on how to get there,” Wolf said. He said that would give it further thought once he saw the final legislation.
While Wolf said no agreement was reached regarding the bills being pursued by legislative Republicans, he said during the call “we all acknowledged that we have differences of opinion as we go into this, but we also acknowledged we’re trying to do the same thing.”
In the weeks leading to the vote on SB 613, GOP lawmakers have criticized the business closure order and waiver process for businesses seeking exemptions to stay open as arbitrary and lacking transparency. Democratic lawmakers have charged GOP lawmakers with trying to tie the governor’s hands during an emergency. 
During House floor debate Tuesday, lawmakers shared many anecdotal stories about how the pandemic and government response has affected their constituents. 
Meanwhile, the House voted unanimously to concur with Senate Bill 841 addressing the pandemic’s impact on local governments. The bill goes to Wolf’s desk. This bill provides for extensions in school property tax payments, allows local governments to conduct remote meetings, allows notaries to do business remotely through electronic communications, allows school districts to renegotiate contracts with service providers to reflect the impact of closings and extends deadlines for businesses to make payments under the state Educational Improvement Tax Credit program. 
The House Appropriations Committee also approved House Bill 2387, a vehicle for the Fiscal Year 2020-21 state budget, by a party line vote.  The proposed general appropriations bill uses current state revenue figures and appropriations as a starting point for the next budget. 
House Majority Appropriations Chairman Stan Saylor, R-York, said having a vehicle bill is the traditional way to start the budget process. He said talks are already underway with the Governor’s Office about the next budget.
The House also, by unanimous 202-0 vote, concurred in Senate language on legislation (SB 841) that would reauthorize the Pennsylvania Health Care Cost Containment Council, require reporting on COVID-19 related matters, and would also allow local governments, notaries to operate remotely and with electronic processes.  And several other tax credit bills eventually passed the chamber on a series of unanimous votes.
Q/As on Tuesday afternoon:
Dr. Levine said that investigation of issues and complaints at LTC facilities was currently on hold, but that the Depar
tment has an anonymous complaint line for workers.  When asked, she said  there are occasions where the Department may give approval for some variances from guidelines established for these facilities.  She noted that in areas with significant community spread, the Department expects to see additional positives because of the daily movements of workers, cleaning staff and food service employees.  She said the Department would work on data relating to deaths and staff with positive test results in nursing homes.
A series of questions related to gathering of data on testing, demographics, etc.  She said that the data the Department has is not complete, noting that 60 percent of the reports received have key demographic data missing.  She said that while they appreciate the jobs being done by hospitals, providers and laboratories, she has instructed them that all demographic information is mandated for reports.  When asked, she said that the Department could not enforce the requirement that laboratories report all of this data.  Nevertheless, Dr. Levine said the state does plan to release additional geographic and demographic information in the near future.
She was asked about her reaction to legislative initiatives regarding safe vs. unsafe businesses, rather than life sustaining essential businesses.  Dr. Levine said, “the Governor has done a fantastic job of defining life sustaining essential jobs.  That’s the correct designation.  The mitigation efforts have been working.  We’ve gone from 1,900 new cases to 1,100 cases/day.  We have 25,000 positive cases in the Commonwealth, but without his orders, the projection was more than 60,000 by now.”
When asked whether she still thinks mitigation efforts may take two months, Dr. Levine said “We’d like to see the curve bend, and it won’t necessarily be two months for parts of the state, but we have to take that day by day and week by week with the models we have.  If House and Senate pass legislation to reopen businesses now, the Governor will address that if and when it’s passed.
She said that the Wolf Administration is having active discussions on new guidance for grocery and big box stores regarding limits on customer numbers, necessary actions and percentages of maximum capacity permissible.
In terms of reopening the state’s businesses, Dr. Levine said, “We don’t have a hard and fast metric  for that decision, but we need one and soon will have that.  We are looking at many different factors including surveillance testing.  When the number of new cases is going down daily and there are no new cases, we can consider that on a gradual basis, provided there are no flare ups.  But the course of the virus will affect our decision making.
A number of testing related questions were raised, including how someone can get testing if they don’t own a car.  Dr. Levine said we don’t want them taking public transportation, and if there are not enough sites, it’s a real challenge.  It’s a completely different issue in rural counties, she said, “We have to brainstorm.”
She said that the right test is not available at this time, but when it is, the State will get it for our laboratory and for the commercial labs – it’d be great if they were available to do that, but not looking like it. The number of tests is decreasing, and nationally its been suggested that this is because of the CDC guidelines for who is eligible –
How many tests would be necessary to do population based testing?  Levine said, “ It’s just really difficult to access the chemicals and reagents – not sure it will be available when we start reopening businesses, but by summer with serological testing.”
Asked about her comments on RiteAid expanding COVID testing, Dr. Levine said she didn’t know that for certain, but that the state would support any expansion of testing, and see that as a positive development. 
The number of tests given daily is also declining, and Levine said that could be because the mass testing sites are closed, so they were producing a significant number of tests.  The testing site in East Stroudsburg is still being planned.  She said, I hope it’s open later this week or certainly next week.  Other sites will prioritize health care workers, and those who are sick, symptomatic and seniors.
She was asked if there were places that hospitals are overwhelmed?  Levine said, “ I don’t know that they are anywhere.  Some have significantly more patients, and need masks and gowns, but so far, we are doing well.  We’re watching that really carefully.
The Department is planning an alternative care facility in East Stroudsburg for those improving but not quite ready to return home, but there is no timeline on when that opens.
DHHS Region 3 Offering Telehealth Learning Series on SUD Treatment and Recovery Support
Region 3’s DHHS office is holding a series of facilitated discussions between providers and subject matter experts. For this reason, they have limited each session to 300 individual logins. Log in early to increase the chance you will get in. If you do not get into the room, please know that each session is the same, discussion and question and answer format. We established 8 sessions to spread out participation. If you do not get in, please plan to log into a later session. Also, we will be creating an “FAQ” document based on the discussions in each section, so please check back on the website for additional resources.
Each session features:

  • Live, one-hour sessions every week for at least 5 weeks via Zoom video conferencing (we may add more weeks based on demand!). Each session will include at least 45 minutes of peer-to-peer conversation and information exchange and “Top Five” tips and lessons learned
  • Access to experienced providers and others with expertise in providing services using videoconferencing (telehealth) and telephone for SUD treatment and recovery support
  • Access to professionals with expertise in protected health information and 42CFR Part 2
  • Training tools, checklists, and other relevant resources

The Series’ 6th Session is slated for Wednesday, April 15, 2020 @ 1:00 pm Eastern
To join the online Zoom Meeting, log on at https://umsystem.zoom.us/j/127156354 
Meeting ID: 127 156 354
Click here for “Top 5” slides and podcast from previous sessions