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Private, public clinics with few coronavirus tests must choose most at-risk

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The Missouri Department of Health and Senior Services says around April 1, the state will begin testing all Missourians who have a fever over 100.4 degrees and a cough. That will give more accurate numbers for who actually has the coronavirus.

Dr. Adam Wheeler of a mid-Missouri practice called Big Tree Medical Home says we only know the extreme cases right now and not the full scope of the coronavirus.

“Over 99 percent of people who have coronavirus have a fever and if you have a fever, you shouldn’t be going to work anyway, whether it be coronavirus or something else. So, we’d like to be a lot more precise than that and hopefully, eventually, we will be more precise than that. But at this time, that’s all we’ve got,” Wheeler says.

A private lab has stocked Wheeler with 20 test kits, and his clinic has 4,000 patients, which means tests are not administered to all patients with the symptoms.

“It’s going to depend on clinical judgment on a case by case basis, of course. In general, people who are low-risk and who don’t have a lot of exposures, testing is not going to help them much.”

The Kansas City Star reports Congressman Emmanuel Cleaver is frustrated with the few tests available at some Kansas City health clinics and the 10 kits available at the Samuel U. Rodgers Health Center.

Wheeler, like many doctors and hospitals, gets his tests from a private lab and they cost him about 90 dollars each.

Big Tree has gone to what he calls Sonic-style appointments– that is, drive-up visits for tests, treatment, and medications he supplies at the clinic.

“We’ve been stocking up on the antibiotics to treat the inevitable post-viral infections. Most of the deaths that have occurred from coronavirus, about 85 percent, have happened due to the virus affecting the lung itself. But just like with any upper-respiratory-tract infection, we would expect to have post-viral pneumonias, ear infections, sinus infections, that kind of thing,” says Wheeler.

If patients are self-monitoring, Wheeler says the most common symptom is a fever.

“That’s a really big warning sign because in adults hardly anything gives you fever that’s not significant: influenza, now coronavirus, then other significant illnesses. Then there’s shortness of breath.”

Like many providers, Wheeler is doing many of his visits through telemedicine.

 

Missouri Hospital Association: There are laws we need changed in the short term to deal with coronavirus

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As of this posting, two Missourians have tested positive for the coronavirus out of 73 tested. Others are being triaged through clinics, healthcare providers, telemedicine, and hospitals.

The burden on hospitals at this time is checking, testing and treating symptomatic patients who come into the emergency rooms– whether they have COVID-19 or not. That could change as more patients need acute care for the more severe symptoms.

Missouri Hospital Association spokesperson Dave Dillon says his members are and have been, preparing for months.

Here are excerpts from our interview:

Dillon: The changes are occurring really quickly. We have been working with our state’s federal Congressional delegation for literally months now to move to provide the tools that hospitals need to address this crisis in Missouri particularly but also nationwide because clearly this is something that is international.

The set of tools that hospitals need is very similar across the country.

Missourinet: Right now, are the hospitals ready?

Dillon: The hospitals are ready certainly for what we are seeing now. The goal is to not have something similar to what is currently going on in Italy, them being up against the far end of their capacity to deal with individuals who are sick, especially.  The goal in Missouri and elsewhere is to avoid that level of this pandemic. If we take the right steps now through the way that we’re managing the crisis, partially through public health, partially through public information and partially through the way that hospitals interact with the worried well, as well as those who are infected with the virus, then we can flatten the curve.

Missourinet: You mentioned tools, what do you need to prepare?

Dillon: For hospitals, it’s essential to not only see those resources come down in the way of funding but also there are significant laws that govern how hospitals operate. What we need is a degree of flexibility in the laws so that we can ensure that we protect the frontline caregivers, protect the public who may think that they have the coronavirus but do not who come to us for care and in that environment become exposed.

Missourinet: Tell me about some of the specific laws, are they mandated by Congress?

Dillon: No, what it takes is action by the Administration and we are hoping, much like what we saw with the funding for this crisis, that members of Congress can pressure the Administration to quickly take the action that will be necessary to get the resources down to the front lines of care.

One of the most important is EMTALA, the Emergency Medical Treatment and Active Labor Act.  That means that anybody who presents themselves to the hospital for care, whatever their problem is, the hospital is required to assess them and stabilize them. That law requires that every individual that comes in our door, that believes they have the coronavirus that we treat them in the hospital setting. That isn’t the best place for what we expect will be a surge of a combination of people who actually do have the virus and individuals who don’t.

It would make a tremendous difference to create a site off of the hospital campus or on the campus away from the emergency department where we can test and treat and not expose the frontline caregivers or people being tested.

Missourinet: What else do you need from the Trump Administration?

Dillon: The question is whether the Administration will properly resource the Cabinet-level positions and below that. For example, the Department of Health and Human Services that runs Medicare and Medicaid. The rules that govern those programs that take care of most of the seniors, the population that is most at risk. We want to make sure that all of the regulations that address care for them, whether that’s in a hospital, a nursing home or in the community, allow us to most effectively deliver care to them. That means that the federal government agrees to pay for things that are not even listed in the current payment scheme, whether that is testing for something that doesn’t have a test code.

All of these things are very small changes but allow a great degree of latitude in the way that care can be delivered.

Missourinet: Do your hospitals have all the test kits that they need right now?

Dillon: The answer is hard to give. The demand for testing is probably higher than the number of kits even available in Missouri. The real issue is whether a citizen can walk into their physician’s office or the emergency department and say, ‘I want to be tested, I think I have coronavirus.” A clinician can ask questions … and potentially eliminate that person who is likely to be at risk. So it’s hard to know what that right number is. Certainly, we would prefer to have more active surveillance of individuals who may be at risk but are not necessarily symptomatic would be optimal. There’s nowhere in the country that has the number of test kits that they would like to have at this point.