Roundtable: How local hospitals are managing the 'tripledemic'

S1: The holidays are here again , and with it comes another wave of COVID. I'm Matt Hoffman and this is KPBS roundtable. Rinse and repeat. San Diego hospitals are beginning to fill up again as we approach winter. Wastewater shows us that the amount of COVID 19 in the community is once again sharply increasing. But this year , there's another factor. After nearly two seasons of almost no flu , it's back in a big way in San Diego. All of this is happening as hospital leaders are having to balance staffing and rising costs as they urge San Diegans to help relieve the burden of what some are calling a triple demic. Joining us to discuss the state of COVID 19 RSV and the flu this week on a special edition of roundtable are Dr. Chris Longhurst. He's the chief medical and digital officer at UC San Diego Health. Dr. William Seng is here with us. He's Kaiser Permanente , San Diego's assistant chief of staff. And Dr. Eric McDonald is here. He's the county's chief medical officer and works very closely with all of the region's medical systems. I want to welcome you all to this very special edition of KPBS roundtable. First question is going to go to everybody. We've heard a lot about this being called a triple demic , COVID flu and RSV. Is that how you all would classify this locally ? And we'll start with you , doctor , saying.

S2: You know , it definitely was a triple demic and I guess I would throw into there at the time this is happening. We also had monkeypox as well. So you may say there was four things going on. What I would say is , you know , we as San Diegans have worked very closely together as a health systems followed in conjunction with the county Health and Human Services. So I think we've had the experience of the past three years to help us get through this pandemic. But , yes , this was definitely a triple demic. We definitely saw the rise of all three viruses , and we are still seeing the continue to rise of both COVID as well as the flu.

S1:

S3: We're certainly seeing all three viruses go up. Now , the good news is it turns out that it's very hard for a single individual to get two or three viruses at the same time. Not impossible. But we're seeing a lot of patients with one of those viruses , and that's definitely creating strain on our health systems.

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S4: And we can talk about that a little bit more as the conversation goes on. I think the good news is that RSV is on the decline and fortunately , I think the other two , although this last week there was a slight dip , I think where they're going to be with us for the rest of the winter as as things move along.

S1: So let's get into what it's like to run a hospital right now. And this one's going to go to you , Dr. Longhurst. What are you seeing ? And we're starting with you on this one because a headline this week was that UC San Diego Health is running out of beds for patients.

S3: And that's a combination of things like delayed care as well as market shifts. But we are short on beds on a daily basis. We've got emergency department patients who've been admitted to the hospital that we have to keep in the hallway for 12 or sometimes 24 hours before we can make a hospital bed available on the inpatient side. And of course , patients come in different ways to the hospital. And so we have scheduled surgeries that will need hospitalizations afterwards. And we don't want to deny anybody needed care. And so it's a constant struggle to maintain those beds and turn everything over in an efficient way.

S1: And when you say delayed care , is that something that maybe wasn't an issue before and now it's like emergent ? Sure.

S3: It can be all sorts of things. I mean , we published data last year showing that during the pandemic , fewer people sought preventive care. And as a result , we're actually seeing more late stage cancers than we saw previously. And so those type of things are contributing to higher health care utilization and costs.

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S2: In fact , if you look at the AMA , they actually sent as a group of physicians , sent a letter to President Biden asking for help. This is not an individual hospital problem or even a San Diego problem. This is a national problem. And the shortage and the pandemic has really taken a lot of resources in terms of staffing resources out of our health system. So all of us are feeling the pinch. I agree with Dr. Longhurst that there are times when the wait is going to be much higher. And so I ask the community to really be patient with us. We really are doing whatever we can to make sure San Diegans get the best care possible. But it is an issue across the county.

S1: And we know that AMA stands for American Medical Association. Dr. McDonald , you look at this from a county wide perspective.

S4: Had to say. It's not just these respiratory viruses. A lot of the medical conditions that are resulting in need to see a physician urgently or emotionally as it's clearly gone up. I think in the last four weeks , five weeks , we've had ten of the record numbers of individuals being seen in emergency departments that we've ever seen tracking this over the number of years. And again , the majority of them are not respiratory. They're actually all the other things that bring people to the hospital. So I think it's important to keep that in mind. And when it's this burdened , anything we can do to keep that down is important , which is why we spend a lot of time with talking about the system as a whole , what people can do to avoid going to the hospital in the first place , and then going to the right place in the medical care system or to primary care or urgent care or the E.D. and then really looking systemwide who's in the hospital. And then when they leave the hospital , where do they go to the go to skilled nursing facilities , back to the community. And there's a flow of patients through the entire system. And if there's a bottleneck in any one spot , it can really cause the entire system to be extra burdened.

S1: And we know that there's surge tests that are set up across the county , even if they're not being used right now. And if you look at the state data in terms of hospitalizations , we're tracking almost the same as last year and last winter. That is the peak was about 1300 people admitted throughout the county.

S4: Again , one of the things that we're blessed with in San Diego is something called the Health Services Capacity Task Force , in which we meet on a regular basis and discuss how to level load the system to make sure the entire system can handle the strain. A good example of that is our pediatric hospital early in COVID being willing to accept older patients when the adult hospitals were overburdened , and then more recently when our local children's hospital was seeing record numbers of children , they were prepared to be able to send younger or older children , I would say , to the adult hospitals if needed. We didn't have to trigger that. But again , those are the kinds of things that are being done behind the scenes to make sure that the system can handle the load overall.

S1: And this is going to be a question for everyone. And we'll start with you on this one. Dr. Longhurst Generally , why are we in this situation Again , we're we're forecasting a third straight winter surge. I mean , we know that many mask mandates are gone , a lot of COVID restrictions , some people basically back to a pre-pandemic lifestyle. So along those lines , is this necessarily surprising or.

S3: You know , I really don't think it's surprising. I think we predicted this six , nine months ago. We know that COVID , as it settles into an epidemic status , is going to cause seasonal infections. But when you layer that on top of the flu and RSV and other things , it's not surprising that we're seeing this surge. What is interesting is that children's hospitals , like Dr. McDonald said , have been dealing with respiratory surges for as long as there have been children's hospitals. Every winter we slow down elective cases at children's hospitals because , you know , there'll be a substantial number of infants , toddlers and children hospitalized with respiratory disease. That has not historically been the case at adult hospitals. And so it's new for us as adult health systems dealing with this surge. But even now , as we're seeing this high number of COVID and influenza cases , it's still 10% or so of our emergency department volume. So to Dr. MacDonald's point , 90% of that volume is still coming from other cases.

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S2: I mean , I think one thing in terms of San Diego that I haven't seen anyplace else is really the collaboration between the hospitals we speak on a regular basis. And when it comes to surges in capacity issues , we don't think of it as my patient or your patient. It really it's San Diego patient. And how do we work together to to improve that , to take care of our neighbors , take care of family , take your community. So I think we can rest assured that we are working together to make sure that San Diego and get the best care and best outcome possible.

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S4: I mean , don't get me wrong , there's competition out there , but everyone knows that every every other partner in the system is necessary. And we couldn't do this alone , especially during these times of stress.

S1: And , Dr. McDonald , we know that just 18% of San Diegans have opted for these recently released Bivalent boosters. They were designed to go after the virus's latest variants.

S4: And so it clearly is matters. And we're about the same as the rest of the country. We might be slightly better than the state of California is slightly better than the national average , but there are states that are doing better than we are and we just need to do better as a whole. Generally , we end up with about a third of San Diegans getting the flu shot every year. We need to do at least that well with the booster. And in fact , we need to do much better with anybody who's at risk. And frankly , anybody over the age of 55 needs to get their booster right away.

S1: And Dr. Langer's , go ahead.

S3: You know , for those who are over 55 or otherwise at high risk because they're immunocompromised , those are the people that we really want to prioritize from a harm reduction standpoint for getting the boosters. You know , if a third of San Diego gets the boosters , but it's all the people who are at high risk , that would be terrific. The reality is that we have a lot of folks who are not at high risk getting the boosters and people who are at high risk who have not yet gotten those boosters.

S1: And , Doctor , same question for you. You know , while these vaccines still provide protection against serious illness with these latest variants , there is sort of a downside. Those who got infected before and were sick , they had the choice of two COVID treatments. But one of those doesn't work anymore. Neither does a preventative treatment that's been hailed as a lifesaver for the immunocompromised.

S2: You know , I think it was November 30th when FDA announced that Bev was no longer allowed to be used because they were ineffective. You know , the variance is really throwing a little thorn on our medical side , but we can deal with this. We have other treatments available. We've got packs limit for people over 50. You have to if you test positive and you're over 50 , please ask your personal provider about how to obtain that. You know , certain populations really get the benefit out of that. We also still have remdesivir , so that's also an option as well. Monoclonal is out right now , including ever shield , which you talked about for the immunocompromised. But we also have a last resort , Molnupiravir , which we don't use as much , but it is something that's available. So our arsenal may have decreased , but we still have very strong , powerful medications that we can use to reduce hospital admissions , but more importantly , reduce death.

S1: And Bev , was that monoclonal antibody treatment that we were talking about ? You're listening to KPBS roundtable. And this week , we're hearing from some local health experts on the local respiratory virus situation. Our guests are Dr. Chris Longhurst from UC San Diego Health. Dr. Williams Singh from Kaiser Permanente , San Diego. And Dr. Eric McDonald from the county Health Department is here with us. Dr. Longhurst , we talked about this a little bit earlier , but you mentioned to me this week it's sort of surprising that you're in this situation where , you know , you have to make some more space beds for patients because we've been through to past surges before. And we know you said some of that's because of delayed care. But have we proven generally you think that we can live with this virus , COVID 19 and anybody else ? Feel free to jump in as well.

S3: Well , it is interesting because we've had these previous surges and as Dr. McDonald said , you know , we peaked at 16 , 1800 patients with COVID last winter. We actually anticipate without a new variant that will have fewer COVID patients hospitalized this winter. But you add in the flu patients and the other diagnoses that are unrelated to respiratory infections , and it's really just unprecedented demand on our health system. And so to your point , that is why we are reconfiguring places where we have not traditionally cared for patients in our licensed space so that we can safely care for additional patients and beds.

S1: I know you were saying that that was a conference rooms , things like that. And a question for everybody. I remember early on in the pandemic , you know , reading stories about patients on their deathbeds with COVID still not believing that they had been infected or that the vaccines did anything for them. Do you guys still face those challenges now , you know , three years in ? And if you do , how do you cut through the noise ? Go ahead , Doctor saying.

S2: I think the the whole community and even the press has been very impressive in terms of getting the information out there. So the people who are not going to believe in it are never going to change their mind. But we're not we're not seeing that as much. I think there's enough information that people can make good decisions. And as such , I'm seeing less and less of that. So I'm thankful about that.

S3: I agree with that. And I would add in that when we look at our mortality rate and case fatality ratio over the last three years , which we've been doing recently , we're seeing that drop year by year. And so the likelihood of going to the intensive care unit or then subsequently dying has dropped significantly for a variety of reasons. It could be partly to the variant , but it's certainly credit to the vaccinations monoclonal antibodies. And as you mentioned , Matt Pax love it as well.

S1:

S4: So I think it's about on average , 15 years older now in San Diego. That was towards the beginning of the pandemic , which just goes back to reinforce how key it is to be sure that those who are older , San Diego and actually get their booster vaccines and those who have older saying they get it in our lives actually do things to protect those providers.

S1: And we know that some health systems , they've been trying to get as many scheduled surgeries and procedures done as possible. And that's because in past surges , some of those had to be postponed.

S2: And and we've done amazingly and then we've cut it by over 50% , if not more , by now. Hopefully that doesn't happen. But I think like any other hospital , we do want to make sure that we're prepared for anything. So if and when we have to , we will have to make that decision. But as of now , we're trying to build up capacity and rooms and prepare for the contingent planning. We've been doing that for about three month already. And hopefully with this coming winter , the COVID may be a little milder , hopefully with all the immunization and history of COVID infection , so that you have some level of protection at this point.

S1:

S3: They're not somebody actively bleeding. They're still really important , right ? And so we do everything we can to avoid rescheduling or delaying or deferring surgeries. Unfortunately , it is rarely necessary , often not for more than a day or two , but these are important procedures that people desperately need. And so we have to balance the needs in our emergency department , the needs in our operating rooms , and our surgeons and other sources of patients that are scheduled for admission for chemotherapy and other reasons.

S1: And , Dr. McDonald , the CDC says that we're at about a ten year high for flu hospitalizations nationwide for this time of year.

S4: But I think that what I like to do is sort of go upstream a little bit and talk about how. We can do things to prevent actually arriving in the hospital in the first place. And so I think. Number one , you can get to buy valent vaccine. But number two , if you do have symptoms , you should have a plan to get tested. And if you do get tested , you can be treated actually earlier and the earlier you're treated , the less likely you are to have a bad outcome. So we have actually test to treat sites all over the county that are free for COVID. And just last week , we announced that seven of those sites actually test to treat for flu on top of it. So the earlier you can identify illness be sequestered from other people , you see , don't spread it and then get yourself treated if you're somebody who's eligible is very important.

S1: And to be clear here , I've heard some people say that , you know , with these new BQ one BQ 1.1 the at home tests don't work.

S4: And again , if you have any doubt about a home test , that access one of the county sites.

S1:

S2: Well , we can also squeeze the virus on the other end with early treatment so that we can limit the morbidity and mortality to as small as possible so that our community continues to thrive through this winter.

S1: And recently , the state's top doctor held a briefing where he said that hospitals were already struggling with RSV cases in addition to COVID and flu.

S4: And it isn't just the hospitals , but it's the prehospital system , it's the skilled nursing facilities. Really. Everybody and medical care is been tapped out from this from this pandemic. And we all are feeling that stress.

S1: Do we know if that's because staff are getting sick like they were before ? I remember the conversation with Scripps Health chief medical officer. She said that some of their staff , their kids were getting sick and they were having to go home with them.

S3: So like Dr. McDonald said , there's just a lot of burnout among all of our team members , our physicians , our frontline staff. And on top of that , we do have staff are getting sick , over 35 tested positive just in the last 24 hours at UC San Diego Health. This is creating kind of a perfect storm because with the great resignation , we're seeing staffing costs increase. With inflation , we're seeing supply chain costs increase and we're talking double digit increases , you know , 20 , 30%. At the same time , our reimbursement for caring for patients is not increasing in any significant manner from our payers who , you know , frankly , have recorded record profits over the last couple of years. So I think our country is really going to have to face this and what it means.

S1: And locally , RSV is on the decline , but flu is still high and this season more than 50% of cases are in those 17 and under. And we also know that in addition , not a lot of parents have opted for their kids to get vaccines , especially really young kids. And Dr. Longhurst , this question is going to go to you because we know that you're a pediatrician.

S3: Right. Flu does affect children and we certainly recommend flu boosters in certain pediatric patients. But vaccine hesitancy overall has been an increasing problem with the pandemic. And that's another real issue that we have to face as a society , because the roll out of the COVID vaccine has been so polarizing that it's led to decreased rates of childhood immunization for things like measles , mumps and rubella , you know , diseases that we haven't seen in a long time that are now coming back. So an important topic is this vaccine hesitancy. I don't know that it's really impacting this most recent triple demic surge , particularly in children. I'm looking at the data right now and just in the last few weeks , up to one in three patients who are pediatric are presenting for respiratory reasons so much higher than in adults. But again , we don't have a vaccine for RSV.

S1: And we know that the holidays are nearly upon us and more of the holidays.

S2: If you're immunocompromised , don't take that chance. You're on immunosuppressive. Why take that chance ? But if you have to try to do things outdoors , right , instead of having gatherings indoors , enjoy the outdoors , that's much , much safer. And then when you're in a situation where there are going to be people with COVID that you just don't know about , put a mask on. We know these are tried and true ways to prevent infection. Listen to your mom. All right , Wash your hands , cover your cough. These are really , really simple time tested methods that we could just implement again.

S1: And guys have anything that.

S3: I think Dr. saying so that really well listen to your mother. I think it's also important for everybody to take their own risk based approach. You know , there are folks that are at lower risk and they may choose to do activities that others would not , and that's their individual choice. But if you're high risk , if you're elderly , immunocompromised or otherwise , might be at high risk of hospitalization and death from respiratory virus like this , then I would certainly take more precautions than if I were low risk.

S1: And , Dr. McDonald , anything to add ? And I guess , one , what I might have is , you know , what ? If somebody is feeling absolutely fine , they're going to head to a a Christmas party or New Year's party.

S4: But I think that not only should you worry about your own risk and assess that for yourself , but recognize that people around you might be at different risk. And it's really a loving thing to do , frankly , to do things that are not necessarily protecting you , but protecting others. And just be aware that , you know , people do have different tolerances for risk and just be accepting of that , frankly. I don't think we should be shaming anybody in either direction for being more comfortable with accepting risk versus less comfortable.

S1: And especially , as Dr. Sam pointed out , those who are immunocompromised could be at higher risk. So final question here.

S2: I looked at the case fatality rate of our patients in San Diego , and it's always been better than the state. It's always been better than the country or the world. So because all the way from the top down the city or county supervisors or Health and Human services , all the health system , because we work so well together and we communicate because , again , it's not my patient or your patient. It's our San Diego. And because we have taken that approach , I think we do better overall.

S3: Doctor saying. So the words from my mouth , as Dr. McDonald said , we can be institutionally competitive , but very collaborative on a personal and individual basis. We're all here for the same reasons , which is to care for the population of patients that we serve. And many of those populations overlap as well. As Eric said , it's not going to work without every one of those cogs in the wheel pulling their weight. And so the channels that we have for communication across the chief medical officers are critically important. And a lot of our other colleagues have similar back channels.

S1: And , Dr. McDonald , you have the final word here.

S4: And this is hard to beat , actually. You know , listen to your mother and take care of each other. I think those are really important things. Again , please , if you're one of the five out of six and be against that hasn't gotten your bivalent vaccine , but you're eligible for it , please go out and get it. Make sure your mother gets it. Make sure your father gets it , your grandparents get it. I think that's a critical thing that we can do along with the flu shot. I think this will be my final words.

S1: And we're going to have to end it there for this week's edition of KPBS roundtable. And I want to thank our guest so much for being here , Dr. Chris Longhurst , Dr. Williams saying , and Dr. Eric McDonald. Be sure to stream our show any time as a podcast. Roundtables produced by Andrew Bracken and Rebecca Chacon is our technical director. I'm your host , Matt Hoffman. Thanks so much for being here with us. And have a great weekend.