24 minute read
WHAT’S WORKED
What’s Worked, What Hasn’t, and What’s Next How Alaska’s healthcare system is adapting to this pandemic—and preparing for the next
By Danny Kreilkamp
Kerry Tasker T he novel coronavirus pandemic has demanded that healthcare professionals worldwide take a long, hard look at the way their systems are facilitating or hindering their ability to deliver care. For Alaska’s Chief Medical Officer, this period has been an exercise in making the most of the state’s available resources.
When preparations were being made at the beginning of the year, Dr. Anne Zink was focused on two areas where Alaska appeared short-staffed.
“I was particularly concerned about our ICU capacity: nurses, respiratory therapists, ICU doctors, and technicians in that space,” says Zink. “Early on in the pandemic, there was a big emphasis on intubating people quickly. There was a lot of talk about ventilators and the amount of supplies, and that really requires a very subspecialized group of personnel to make sure you can run those machines well.”
Advanced technology requiring specialized care was the other area in which Zink felt Alaska was illequipped. Extracorporeal membrane oxygenation, or ECMO, is one example of a technology that has proved useful in combatting COVID-19 but which the state simply doesn’t possess the means to employ.
A process like ECMO requires the expertise of cardiothoracic surgeons, which Zink says have proved difficult to attract. “You just can’t recruit people to work in the state to do that, and you need a whole team to be able to pull that off. Something like that is a 5- to 10-year process to build up.”
Though valid, Zink’s initial concerns have only been a drop in the bucket of the many disruptions brought about by the virus. And almost a year into the pandemic, Alaska’s healthcare system continues to find new ways of responding and adapting.
What (and Who) Has Worked
Alaska’s infrastructure and technology limitations have required its healthcare system to adopt new approaches to providing care. An increased role in telehealth, onboarding new healthcare workers via conferencing software, and old positions taking on new responsibilities—all part of the everchanging equation.
“I think there was a lot of focus initially on hospital capacity and alternative care sites, but as we’ve been able to slow this pandemic, it has required a whole different skill set,” says Zink.
She points to the contact tracers, quarantine workers in rural communities, and other less celebrated positions that have played vital roles in the state’s response strategy.
And in many cases, new positions are being created entirely to cater to a world in which face coverings and social distancing are the norm.
Lisa Powell is Providence’s Director of HR for Alaska and Oregon.
One development in particular that Powell has noticed is the emergence of hospital monitors. “If you’ve been into a clinic or hospital, someone may have stopped you and taken your temperature and asked you a few questions,” she says, noting that, in some cases, the individuals assuming these new roles aren’t necessarily required to possess healthcare backgrounds.
“In some of our facilities, there are actually folks that monitor social distancing and folks that have to make sure we have enough PPE [personal protective equipment] on hand,” says Powell, adding that existing staff such as nurses and emergency coordinators have had to take on these additional duties.
As far as attracting applicants to some of the more specialized positions, Providence’s Talent Acquisition Director, Robert Dick, echoes Zink’s earlier sentiments on the difficulties associated with recruiting. “Overall, Alaska is a challenging market to get people from the Lower 48 to relocate to… and it has certainly been more challenging adding the pandemic to the equation.”
Doubling down on marketing campaigns has allowed Providence’s hiring efforts to remain steady, with sign-on bonuses also coming into play, Dick explains. “The psychology right now, with all the uncertainty in the market, makes people less compelled to leave a job.”
A Group Effort
But Providence, like many businesses, has been able to lean on a few strategic partnerships it has cultivated to help navigate the pandemic.
The State of Alaska is one of those partners. Acquiring the necessary professional licenses to work legally in the state takes time. And with both the demand and the immediate need for nurses at an all-time high, measures have been taken to fasttrack some of these workers so that they are more readily available to serve on the frontlines.
Dr. Anne Zink, Chief Medical Officer Alaska Department of Health and Social Services
In April, a joint effort between UAA and Alaska’s Board of Nursing offered seventy-two nursing students in good standing an opportunity to graduate a few weeks early. Many of the graduates had already fostered relationships with the hospitals through their time in clinicals, which contributed to a smooth transition for everyone involved.
Alaska Executive Search (AES) is one of the state’s leading staffing agencies, and its relationship with Visit Healthcare—an emergency responsefocused testing company—is another example of companies taking a collaborative approach to problem solving. “We have worked closely with Visit Healthcare—they were able to set up testing sites for the municipality of Anchorage in record time with support from the CAN, CMA, data entry, and contact tracing candidates we provided them,” AES says.
In addition to partnerships within the state, Zink says that for certain situations, Alaska has had to maintain close contact with hospitals in the Pacific Northwest. While Alaska doesn’t possess certain specialized care like ECMO, Zink explains the state does possess the ability to fly someone on a portable ECMO until they’re able to arrive in Seattle. “We’ve had to work closely with Seattle and be like, ‘Hey, you know you are part of our healthcare infrastructure, right? We need to make sure that your beds are available,’” she laughs.
What Hasn’t
Certainly, some of the systems Alaska had in place prior to the pandemic, and those systems that have adjusted in response, have been successful.
Others have not.
“There is a huge need for data—the untold story of this pandemic is the fact that we’re at over half a million tests now, and most of those were coming to us via fax when this first started,” Zink admits. “And we’re not the only state. Most states are really struggling with this.”
Zink says the healthcare community is spending a tremendous amount of time trying to make IT systems work together. “A lot of the time a community is focused on the positive of their contact tracing and they forgot to send it to us or fax it to us or call us—and we don’t have it, so we can’t put it up [on the dashboard].
“So, there’s all these bits and pieces of limitation that other countries who have a more unified healthcare system have not had to deal with.”
A major issue facing patients and providers around the nation is the nature of siloed healthcare in the December 2020 | 37
Dr. Anne Zink, Chief Medical Officer, Alaska Department of Health and Social Services United States. To illustrate this issue, Zink recalls the ravings of a frustrated professor during her residency who was unable to see lab results that were ordered in a different department of the same hospital.
“And that is a good example of the fact that in most hospitals, inpatient can’t see what’s done in the emergency department, the emergency department can’t see what’s done in obstetrics, obstetrics can’t see what’s done in anesthesia— and that’s just within the hospital, let alone what was happening at the other hospitals or what happens in the clinic.”
Part of the reason hospitals are unable to provide a seamless flow of information is due to individual departments each operating their own unique IT systems—IT systems that are incentivized to be proprietary. Electronic medical records or EMRs can be hugely helpful in providing continuity of care as patients are moved through specialties or from facility to facility, but that’s assuming a level of interoperability between
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disparate EMRs that has yet to come to fruition for many healthcare providers. And while there has been an effort by the federal government to address this issue, Zink believes this is like trying to fit square pegs in round holes. “The Health Information Exchange [HIE] is supposed to connect those pieces, but it’s essentially an air traffic controller with a bunch of parts and pieces that don’t want to fit together… And it’s part of the reason our healthcare costs are so expensive.”
What’s Next
At the time of writing, Alaska had just recorded its fourth straight week of daily case-numbers in the triple digits. This alone suggests it will be some time before the pandemic begins to subside. And even when it does—what will come of the next pandemic? And how can the doctors, nurses, administrators, and clinics and hospitals of Alaska’s healthcare system better prepare themselves?
For Zink, the answer is surprisingly simple.
“I think healthcare has been structured around the place, such as the hospital, rather than around the patient. We need systems that put patients first—not systems that are meant for systems. What ways can we make this about patients and not about providers and places? If you’re in hospice, you could be at home and be able to have your doc FaceTime in and your doc doesn’t have to drive there—or you don’t have to die in the hospital.”
Expanding, she adds, “We need to invest in healthcare infrastructure that connects people and we need to invest in public health that’s community-focused. I think there’s been a movement in the healthcare realm for some time in Alaska about sharing information better and working more collaboratively, and I’m hoping we will take this moment to be able to really change the way that we do healthcare and have it be prevention-focused, patient-focused, and utilize the strengths of our communities to keep people healthy and well.”
As a roadmap for this approach, Zink points to the efforts of the Mat-Su community in tackling its opioid crisis.
“I was just really amazed at when the public really engaged in opioid addiction and overdose in combination with the providers, patients, policymakers, and the press. It made a difference: we saw decreased deaths, decreased addiction, and we see real change when that happens.”
Zink believes this approach would not only create a more resilient healthcare system but also a sturdier Alaska economy.
“We have really unique limitations in the state—we don’t have ECMO, we don’t have certain services up here, it’s really hard to recruit healthcare providers. But what we do have is a really strong sense of community. And I think if we invest in prevention, we invest in public health and community strength, it will decrease our healthcare costs, make our businesses more robust, and our communities healthy.”
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Corralling COVID-19
Alaska sets a high bar for COVID-19 testing
By Vanessa Orr
When the COVID-19 pandemic first began, cities and states across the nation were scrambling for everything from information and general guidance to personal protective equipment and testing kits. As it continues to spread, more and more importance has been placed on testing as a way to both identify those with COVID-19 and to begin the contact tracing process.
Despite its size and the fact that many cities and villages are in remote locations, Alaska has excelled at implementing a testing protocol and making it accessible to the public. There are 175 testing offices throughout the state—from single sites in villages such as Ninilchik, Elim, and Unalakleet to roughly two dozen sites within the city of Anchorage. Working together, everyone from the Department of Health & Social Services (DHSS) to municipalities, tribal health services, hospitals, and drug stores have stepped in to make sure that testing is easy and available to those who need it.
“I am very proud of the work we have done together, from our healthcare partners to DHSS and others,” says Audrey Gray, lead public information officer of the Anchorage Emergency Operations Center. “We are a well-tested community, which is assisting us in identifying cases early to prevent further spread of COVID-19 in our community.”
The state has been so effective, in fact, that it was featured in a September 2020 Wall Street Journal article touting it as one of the most comprehensive COVID-19 testing operations in the nation.
Into the Fray
While no one could have predicted how fast the virus would spread across the world and particularly across the nation, DHSS and its community partners geared up early to get testing sites operational.
“In the very beginning, the state was the only entity that had tests; they received the tests from the CDC, and they did all of the specimen testing at their Fairbanks and Anchorage labs,” says Michael Bernstein, chief medical officer of Providence Health & Services Alaska. “Not long after, a number of commercial labs in the US developed their own tests, and we were able to get some of those at hospitals that had testing equipment.
“Initially, the only way to get access to a test was to go to our emergency room, but we realized very quickly as we began seeing more people who needed tests that it was a very poor use of our ER,” he continues. “We were getting overwhelmed.”
Providence, which is the largest healthcare provider in the state, was contacted by Dr. Anne Zink, DHSS’ chief medical officer, who asked about the feasibility of setting up a drive-through testing center on hospital-owned property that was not currently in use.
“We quickly did some remodeling and established a drive-through, and for a period of time, we were the only drivethrough center,” says Bernstein, adding that the state then encouraged other areas to establish similar sites. “As far as organizing and funding, at first we did it ourselves. We had partnerships with Alaska Regional Hospital and Alaska Native Medical Center because they didn’t have testing sites yet, so they put a couple of their people permanently at our site to enter patient information into their own medical records.”
Once the site became even busier, the municipality stepped in to help out. “After seeing the large public response to the testing site, the Municipality of Anchorage [MOA] put out an Invitation to Bid for more testing sites, which was awarded to Visit Healthcare,” says Gray, adding that MOA then began to focus on areas of town that were medically underserved.
Caleb Terpstra, Supervisor, Lake Otis Testing Site
Anchorage is home to seven municipally funded COVID-19 testing sites and a DHSS site at the airport, as well as several privately owned testing sites within healthcare facilities. To create a testing site, Visit Healthcare uses a portable system, including a durable, all-weather tent, that can be set up and taken down each day and sanitized every night at the warehouse. With cold weather coming, testing staff will be housed in small, enclosed mobile buildings as well.
“Visit Healthcare has a team of employees for each site, and they also maintain a mobile team that goes to shelters and assisted living homes,” says Gray. “The warehouse has a logistics manager, office staff, and there is a main lead for the Anchorage operations.”
It takes a village to establish and run a test site—according to Gray, in Anchorage this includes the MOA for contracting, oversight, and some public information; the Alaska Public Health Laboratory and a laboratory in the Lower 48 for running tests; the Alaska State Epidemiology Office for reporting testing outcomes; MOA Traffic and Engineering for traffic patterns at the sites; and contractors who are doing the work.
How It Works
According to the CDC, there are two types of tests available for COVID-19: viral tests, which tell individuals if they have a current infection, and antibody tests that tell them if they had a past infection. People who should get tested are those with symptoms of COVID-19; those who have had close contact (within 6 feet of an infected person for as little as 15 minutes in a 24-hour period) with someone confirmed to have COVID-19; and people who have been asked to or referred to get tested by healthcare providers or another health facility.
According to Gray, anyone can be tested at MOA sites, a policy that has changed significantly since the beginning of the COVID-19 response. “Initially it was only symptomatic people, then it expanded to highrisk contacts of positive cases, and then to everyone who desired a test,” she says, adding that testing is not recommended after being ill with COVID-19 because the dead virus can continue to shed from the body for many months after recovery.
To get tested, individuals need to pre-register and to check each site’s requirements. That information can be found on the DHSS COVID-19 website. It’s important to note that each site has different rules; some healthcare facilities only take their own patients; other sites may or may not require a medical referral; and some will not accept medical vouchers.
The actual testing process is simple; at the Lake Otis site on Providence’s property, once a person’s registration December 2020 | 41
Ashley Johnson, Manager, Lake Otis Testing Site
is verified, they receive instructions from a team member, who verifies their identity and then performs the test.
“Our sites are using the SARS COV-2 assay with both oral and nasal swabs, though if there are small children, they may do a nasal swab instead of an oral one if needed,” says Gray.
“The team members are personable and have even been known to sing Baby Shark to toddlers to make the swabbing process more comfortable,” she adds. “They also help alleviate fears of the children about the process.”
Once testing is complete, patients receive instructions about when they should expect their results and a follow-up email with instructions. If the test comes back positive, they will also receive a call from a nurse, as well as a follow-up call from public health.
“While it can take up to seven days to get results, people frequently get them in two to four days,” says Caleb Terpstra, manager of Providence Rehabilitation Services and Outpatient Pediatric Therapies, who serves as supervisor of the Lake Otis site.
He adds that those coming for drivethrough testing can rest assured that it is a safe and efficient process.
“We are hyper-careful of the process and protecting the workers, and with more than 32,000 tests [performed] at the Lake Otis location, not one caregiver has been found to have gotten COVID-19 from this station,” says Terpstra, adding that patients remain in their cars and testers are fully outfitted in personal protective equipment.
“I’ve been really encouraged by the level of support that we’ve gotten from
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the state—even when we had supply chain shortages at the beginning, the municipality and the state really stepped up with help providing testing kits and supplies and answering questions,” he adds. “They are taking testing very seriously, and it gives me quite a bit of confidence that we’re doing it right in Alaska.”
Public and Private Support
As with any such endeavor, there was a learning curve at the beginning, and, as more is learned about COVID-19, testing sites are adapting to meet changes in CDC recommendations, as well as to make the process more comfortable for patients and testing staff.
“While having enough supplies was a real issue at the beginning, we’re not as worried about that now, though it is still a limited resource, so we need to be careful,” says Terpstra. “We have also expanded the scope of who we test; we’ve transitioned from only testing patients with symptoms to those who are asymptomatic but may need clearance for travel or work.”
He adds that recently the municipality has asked for testing to include more of the general population, most specifically those people in known high-risk categories.
While Providence staff originally worked at the Lake Otis site, it became necessary to find a replacement workforce so employees could go back to work inside the hospital. Providence has since contracted with Fairweather to provide staffing and has also switched from using its own EPIC electronic medical record system to register patients to a web application, called covidsecureapp.com, created by Capstone Clinic, which allows for advanced patient testing, notification, and observation tracking.
“Since the introduction of the app, which was developed in record time, we’re seeing wait times significantly reduced,” says Terpstra. The app also provides ways for patients to monitor symptoms, find testing sites, and keep track of their test results.
Having people in the field has allowed the state and health professionals to learn more about the needs of testing staff and Alaska residents.
“While running the drive-through clinic, we learned a lot more about how to keep the staff warm and what needed to be done to keep them protected from symptomatic people; we needed to put in more safety precautions to keep the staff safe,” explains Ashley Johnson, who manages the Lake Otis site and is a continuous improvement specialist for Providence Alaska Medical Center.
“There is also a lot of back-end processing that has to occur; a lot of work needs to be done ahead of time, and there’s a lot of work that happens after the patient leaves to make sure that everything is properly processed and prepared to be sent to the state for processing,” she adds.
People coming through the site also brought increased knowledge as it became apparent that there were gaps in the information they needed. “People had a lot of questions when they came to the site; for example, we realized that a lot of people didn’t know that they needed to quarantine
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Audrey Gray, Lead Public Information Officer, Anchorage Emergency Operations Center
afterwards,” says Johnson. “We learned as we went along the types of things that we needed to provide, like informational fliers, that went beyond testing.”
“Every day we made continuous improvements; every day brought something a little different, so we spent a lot of time observing and monitoring and constantly readjusting,” says Terpstra.
The one thing that they were not expecting, and were very relieved to see, was just how much support they received from the community.
“People had signs in their windows thanking us as heroes, and people dropped off food three or four times a day,” laughs Terpstra. “Our staff was worried about gaining weight! The community support was overwhelming—but in a good way.” 44 | December 2020
Unfortunately, as COVID-19 numbers have started to rise again in Alaska, this type of support is going to be required for the long-term.
“In the first 100 days, we did just under 10,000 tests, and since June 23, we’ve done an additional 23,000 tests, just at the Lake Otis site,” says Terpstra. “But in the past couple of weeks, we’ve been seeing daily averages going up, and now we’re averaging 300 to 350 tests per day.”
As of mid-October, the state had performed more than 634,000 tests with an average turnaround time of 2.6 days. Some people were being tested for the first time, while others required repeat testing.
“I think from a patient experience, things are going really, really well, and the fact that we’ve done this many tests without any of our staff getting sick tells me that we’re doing a quality job,” says Terpstra.
As things continue to change during the pandemic, Bernstein predicts that someday soon, there may be tests that people can take at home instead of having to visit testing sites.
“Looking toward the future— it’s hard to know the timing because these tests would need FDA approval—but someday soon COVID tests could be like the home pregnancy tests you buy in the drug store, and for $5 you’ll be able to test yourself at home to see if you have COVID,” he says, adding that there are already dozens of these types of tests in development.
In the meantime, Alaska’s testing sites will continue to provide safe, accessible testing to the people of the 49th State.
