Timeline February 2020 to May 2020 Critical period

Timeline: February 2020 to May 2020 Critical period at very beginning of the outbreak. Matching 3 separate sources of data. In the beginning… February, 2020 FEB In the eye of Hurricane SARS-Co. V 2 March 2020 Downside of the 1 st wave April – May 2020 APR MAY Connect practice, guidance, and random factors to outcomes? Practice, Operational Factors Local, State, Federal policies and guidance. Implications. Uncontrollable factors page 1

Outcomes: Mortality, Resident health, and Staff health. Morality: Rate per 100 beds per month page 2

Outcomes: Mortality, Resident health, and Staff health. Resident Health: Vital sign temperature page 3

Outcomes: Mortality, Resident health, and Staff health. Staff Health: SARS-Co. V 2 testing page 4

Is an outbreak happening? Mortality and Fever indicators say yes! In the beginning… Feb In the eye of Hurricane SARS-Co. V 2 March – April 2020 Downside of the 1 st wave MAY Once available, staff testing follows same trend as clinical indicators. page 5

Volume, timing and sources of guidance: External In the beginning… Feb CMS, 2 memos, Feb 6 th GA DPH, 1, Feb 4 th Governor’s Office, Feb 28 th In the eye of Hurricane SARS-Co. V 2 March – April 2020 CMS, 2, Mar 4 th CDC, 11, Mar 4 th GA DPH, 7, Mar 13 th FEMA, 1, Mar 29 th GHCA, 35, Mar 2 nd Governor’s Office, 19 IA/ ICS / UPDATES, 118, Mar 2 nd GA Licensing, Mar 14 th Downside of the 1 st wave MAY CMS, 8, Apr 2 th CDC, 13, Apr 15 th DCH Data, Apr 3 rd GA DPH, 3, Apr 7 th GHCA, 31, Apr 1 Governor’s Office, 11, Apr 1 IA/ ICS / UPDATES, 160, Apr 1 Exec Order, 18, Apr 1 page 6

AREAS FOR FURTHER ANALYSES OF ETHICS & POLICY Balance staff empowerment with adherence to guidelines of practice. • When to make a ‘scientific guess’? • Recognizing the limits of guidance from outside sources: Timing, content Recognize incomplete knowledge and still make needed decisions. • Early in the outbreak, testing results lagged behind clinical issues. • Engaging surrounding communities to assist with incomplete decision process. page 7

LESSONS LEARNED Practice and clinical indicators ALWAYS 1 st notice of potential outbreak ALWAYS a time lag between events within your building & guidance from outside. Different agencies supply different bits of advice. There is no one voice. State Health Care Agency = workforce; CDC = infectious agent; CMS = site of care Early in an outbreak, Staff testing results lag behind clinical indicators. Cultivate a community sounding board to help with emergency communications. page 8

THANK YOU!

Case Analysis: COVID 19 outbreak in the nursing center setting page 10