This memo is for those who care about how the coronavirus is spread and the debate raging about that. As always, we seek to transcend silos and dogma to focus on facts and outcomes. The purpose of this post is to provide a framework for leading a discussion about risk management and Personal Protective Equipment, PPE.
image credit: Manex
As we reflect on all of the data from Asian countries, Italy, and New York, I am really concerned that we could be learning collectively, much more rapidly than we are now. I'm grateful to mentors who have asked for more explanation from me about the these emerging issues. The most recent request is from a seasoned board director advisor interested in a review of the nature of systemic risk for hospitals in this pandemic. In looking at the concept of risk as it plays out in the C-suite and reflected in recommendations about levels of personal protective equipment (PPE) to be used by frontline healthcare workers, there sometimes seems to be a lack of clarity or a conflation of concepts of organizational risk in terms of cost, public relations, or executive liability as opposed to the risk of infection inside the facility based on workflow, the "geography of risk" of infection in various parts of the hospital, and what constitutes risk of infection of the hospital workforce based on what is known, suspected, or feared about the physical properties of the virus and exactly how it is transmitted. Our thesis is that this confusion may lead to policies and procedures that increase the risk of infection and incapacitation of frontline staff. A health care executive once famously said of the mission of healthcare and operating cash margins, "no margin, no mission." Recognizing that with no workforce there is no way to carry out the mission of caring for patients, we say "no mission, no margin.''
One factor of systemic risk that we recently learned is that some people who get the coronavirus could be contagious and shed virus for a lot longer than the two-week quarantine period that many countries are using, according to a new study. Researchers looking at cases in China say patients could spread the virus for up to 37 days after they start showing symptoms, according to a study published in the British medical journal The Lancet.
This adds to our point of view that this is a virus whose level of contagion is unknown and potentially unprecedented; therefore it warrants a constantly revised and comprehensive risk assessment approach as individuals and organizations. Here is a risk management plan template to have and guide a discussion with leadership and the team. Download it as a word document or make a copy for your facility.
Other viruses have shown to be shed by infected people in a way that lets the virus actually hang suspended in the air for minutes or even hours. (see attached images from the American Journal of Infection Control) Later, those viruses which are airborne can get breathed in when other people pass by. Measles is a good example of that kind of transmission—the Measles virus can remain infectious in the air for up to two hours after an infected person leaves an area. Some top, world-renowned virologists say that Coronavirus also lives in the air for 3 hours. Perhaps too little is known about this "novel" virus, Coronavirus, SARS-CoV-2; maybe it's inappropriate to draw conclusions about exactly how it is transmitted (more importantly it's too early to say how it's NOT transmitted) today. Hence why a systemic risk assessment and management approach is warranted. One potential “advantage” to and why some organizations may declare, even if it's premature to declare that it’s not airborne (whether it is or not); is that an organization may promote publicly a relatively lower levels of protection Biosafety level 1 Biosafety (BSL1) first row of grid) than what would be recognized as necessary for airborne transmission (minimum BSL 2). For example, defining coronavirus as "droplet only" transmission dictates a lower level, BSL1 of required PPE. This line of messaging would also be highly compatible with aligning policy primarily to available supply chain rather than microbiology or virology based infection risk and related systemic risk consideration. Regardless of what studies academia will pursue to define the ways in which the virus is transmitted; we only need to continue to think in terms of systemic risk assessment terms in my view. Notice that Asian countries who have been successful in mitigation and reducing, or eliminating provider infections have adopted Biological Safety Level 2 (BSL2 & BLS3) PPE (The three levels are outlined in the attached .jpg image grid). Further, if you have an underlying condition (s) or are over the age of 60, it seems reasonable to me to bump up the risk assignment beyond what the ascribed "scope of application" column to the right i.e. from BSL 1-2; from BSL2-3 by scope of application grid, and so on.
Biological Safety Level I-III (top, middle, bottom rows)
A couple of additional data points for consideration are: 1) S. Korea leveraged a minimum most of the time, BSL2 (middle row of the grid attached) and has had no nurse or physician related deaths due to COVID; they leveraged a PPE strategy reflecting BLS2 and when appropriate, and BSL3 levels of protection, along with strategic operations and cultural/management adaptations. These were oriented towards patient and clinician safety as referred to and shared in this blog by physician leaders worldwide. 2) An official in Shanghai confirmed the virus also travelled through aerosol transmission, which means it could float a long distance through the air and cause infection later when it is breathed in. "Aerosol transmission refers to the mixing of the virus with droplets in the air to form aerosols, which causes infection after inhalation, according to medical experts," Shanghai Civil Affairs Bureau deputy head Zeng Qun said at a press briefing, the China Daily reported. "As such, they have called on the public to raise their awareness of the prevention and control of the disease caused by family gatherings." The one thing we could all agree on is that more investigation and analysis of epidemiological data is needed to understand and disseminate what the accurate modes of transmission of the virus actually are. Until then, we can employ common sense risk assessment and risk management approaches!
Sherri Douville CEO & Board Member at Medigram, Inc. Prior to her current work in the mobile privacy, security, health IT and AI industry, Sherri worked in the medical device industry consulting on the areas of physician acceptance and economic feasibility of medical devices. Prior to that, Sherri worked in Field Marketing, Sales and as a National Sales Trainer for over a decade in over a dozen disease states; including with a variety of respiratory infections and treatment. During that time, she leveraged her multi-disciplinary STEM background to help physicians understand the microbiology behind the sensitivity and effectiveness of specific and different pathogens to a range of anti-infective agents
Dr. Art Douville, CMO at Medigram and Attending Neurologist. In addition to practicing Neurology, Dr. Art Douville has held several leadership and administrative positions in healthcare including helping physicians understand and leverage the data by which they're measured. He also has experience as a hospital Chief Medical Officer for two separate health systems. He oversaw both infection control and biohazard governance in hospital environments. Dr. Douville has expertise in clinical integration and was recently Regional Vice President/ Chief Medical Officer at Verity Health System. In this position, Dr. Douville oversaw physician relations, patient safety & quality, regulatory compliance, and the development of innovative clinical programs. He was part of the leadership team to spearhead bundled payment and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) initiatives. Dr. Douville has over a decade of experience leading physician culture and developing leadership, performance improvement, regulatory compliance, clinical process design and implementation, as well as physician alignment.