MMC and St. Joe’s staying one step ahead

NASHUA – As the dynamics and number of COVID-19 cases change on a daily basis, so do procedures, safeguarding and protocols at St. Joseph Hospital, both at its Nashua facility and at the Milford Medical Center.

Concerns have grown as the pandemic spreads that some patients who require immediate attention for non-coronavirus-related illnesses and procedures are reluctant to enter a hospital or emergency department.

“The biggest challenge with the coronavirus pandemic has been having to modify almost all the ways in which we provide patient care to minimize risk to patients and staff,” said Dr. Eduardo Velez, medical director, ICU and pulmonary function laboratory at St. Joseph Hospital.”

For example, Velez said that many patients had to be placed in isolation until COVID test results were returned.

“We have had to stop many routine tests and procedures to be able to use the equipment and supplies we have in the care of coronavirus patients, and we have had to work especially hard to modify what we do in order to bring all those services back,” he said. “And we continue to restrict visitors in order to protect the public from getting infected.”

Dr. Allison Madden, vice president of medical affairs, said St. Joseph’s overall volume is low.

“We are worried about people not coming in for emergency issues and how this might impact their health,” she said. “We’ve made several changes to keep our patients and staff as safe as possible and want to make sure people know our hospital and ER are open and here to serve.”

Dr. Deepak Vatti, chief of emergency medicine and director of the mobile health clinic at St. Joe’s agreed that people are hesitant to go to the hospital right now.

“Yes, people are reluctant to go,” he said. “They watch the news, see what hospitalists look like in major metropolitan areas and may feel they are all like that.”

As medical director of urgent care at the Milford Medical Center, Dr. Jim Martin echoed that concern, saying that the facility has received calls practically every day from patients who are afraid to come to urgent care for fear of contracting the coronavirus or from instructions to not go because the medical center is “overwhelmed” with COVID-19 cases.

“The opposite is true,” Martin noted. “We are taking extraordinary measures to protect patients and staff.  The number of patients coming to urgent care and the ED have plummeted, meaning people are not getting the care that they normally would.”

Convincing patients that the ED and MMC Urgent Care is safe for patients who do not have COVID but have other health conditions requiring the need to be seen in the appropriate facility is a major issue. 

“We are concerned that patients with significant health issues such as stroke, heart attack, etc. are staying home when they should be calling 911 or coming to the ER,” said Dr. Brian Sweeney, EMS medical director at St. Joseph’s. “Delaying emergency care results in increased risk of complications and death.”

Having a new disease with a high rate of spread is the core challenge. According to Vatti, an experienced physician will be able to tell quickly if a patient has strep throat because of the years of research and learning that goes into honing that skill.

“A new disease means learning from a new and growing data set and trying to incorporate that into your practice,” Vatti said. “It is challenging, but it is the essence of what physicians do.”

The lack of visitors for most patients also is trying. Additionally, other challenges include the availability of PPE supplies, uncertainty about modelling for case numbers, uncertainty about disease for its natural course and treatments/vaccines.

Madden said many patients who are diagnosed with COVID-19 at the hospital are able to recover at home, but for patients that need hospitalization, they often also need IV fluids and oxygen.

“We have been using different potential treatments such as hydroxychloroquine and azithromycin,” she said. “We have also partnered with Mayo Clinic to provide convalescent plasma (donated blood product from patients who have recovered from COVID 19 and have high levels of antibodies).”

St. Joseph’s has expanded dramatically their ability care for patients requiring ICU level care and ventilators.

“We have a generous donation of 25 iPads from Dynamic Strength and Conditioning in Nashua that we are setting up to use for family communication and consultations or other communication,” Madden shared.

Vatti said that over the past few months, every aspect of the St. Joseph’s hospital system has been bolstered and streamlined to handle the pandemic.

“At Milford Medical Center, they have a separate space for suspected COVID patients and can test as needed,” he went on to say. “We don’t see ourselves as two hospital but rather one organization with different locations. We have doctors that work both in the urgent care and the ER in Nashua and we use the same computer system, so all information is instantly available.”

Milford Urgent Care has a process where patients with suspected COVID are screened on the phone prior to entering the building.  They are then told to use a side door and are escorted into a dedicated “COVID room,” where they can be evaluated by MMC staff in full PPE. 

“This keeps the rest of the facility and patients safe from any exposure to a patient with the possibility of having COVID,” Sweeney said. “Regarding a patient who presents to MMC and needs to be transferred to the ED, we have direct communication with the ED to inform them that this patient is COVID suspect so they can take the proper precautions.”

“Milford Medical Center is a full-service MD-staffed urgent care, but is not a freestanding hospital as it had been in the past,” Madden explained. “It has been configured to act as an overflow site for short stays if we were to fill up all of our beds and surge capacity here at St. Joseph’s in Nashua.”

Currently, Milford Urgent Care is open 8 a.m. to 8 p.m., but volume is currently very low. Just as in Nashua, processes are in place to keep patients separate with known or suspected COVID-19 away from patients coming in for non-COVID-19 complaints.

“MMC uses a screener, with only one entrance, for all individuals entering the facility to check for symptoms/fever,” Martin noted. “If the person is found to have either, they are asked to go to their vehicle, call us and speak with a nurse regarding their symptoms.  Based on this information, measures are taken to use proper PPE, use a separate entrance and room specifically and only used for potential COVID-19 patients. We coordinate our prevention and preparedness measures with the ED/SJH.”

Another area that has been finely tuned by doctors and nurses within the St. Joseph health care system is the time necessary for preventative action before caring for a patient with COVID or one considered to potentially have the disease.

“Initially, it slowed down processes a bit, but we adapted quickly, and now the patient may notice a few extra steps in the process, but it is all for their protection and safe treatment,” Vatti said. “I think the patients appreciate it and they feel safe.”

Shared Madden, “It does take a few minutes longer to put on the protective gear needed, but we are able to care for patients as always, and it is not affecting our ability to operate.”

Velez agreed that the staff also has had “to work very hard as the need for use of personal protective equipment involves many steps every time they interact with a patient.” 

Reopening is the next phase that many area hospitals are facing – all in due time, with safeguards in place, officials said.

“We cannot wait to get our patients back in for health care, surgery and move forward, but have to do so in the safest way possible and keep a close eye on the number of new COVID cases admitted,” Madden said.

“From the ER perspective, we operate 24/7/365,” Vatti said. “The urgent care in Milford has also been operating at full capacity without any major changes.”

For folks concerned about “elective” surgeries or procedures, Madden said that most surgery is medically necessary, but the term “elective” can be a bit misleading.

“Some surgery is emergent like a ruptured appendix or c-section,” she explained. “Others can be often put off like a joint replacement. However, the vast majority of surgeries are deemed medically necessary.  Even cosmetic surgery typically has a strong reason it is being done such as reconstruction.  The critical part is if the delaying of a medically necessary surgery would have a negative impact on the patient’s health.”

Vatti added, “A required surgery would be something that is time sensitive and without it can have permanent effects or be a threat to life or limb. Elective means it may be needed eventually, but can be put off.”

PPE remains a challenge. Hospitals are given “allocations” of PPE supplies based on historical usage patterns, and they are not able to rely on any increase beyond that.

“This has created a challenge everywhere,” Madden siad. “We are fortunate to have an amazing, hard-working supply chain team and feel that at St. Joseph’s right now we have what we need to care for our patients safely.”

The number of ambulances coming to the hospital also has gone down with COVID-19, which is a concern to many as patients may be doing their own self-evaluation or prolonging the inevitable.

“This is a concern we have,” Madden continued. “We know it is unlikely that all the patients with emergencies have somehow gotten better, and there seems to be less emergencies and patients presenting later where treatment is difficult or impossible.”

Regarding EMS traffic, Sweeney said they have seen a decrease in the number of ambulances to the hospital. 

“This is felt to be a direct response to the stay- at-home order issued by the governor,” he said.

“With less people driving, taking part in recreational activities, there has been less accidents resulting in fewer visits to the ED.  However, there is also less people calling 911 for non-COVID-related emergencies (heart attack, stroke, etc.) and we are concerned that by not calling 911 for true emergencies is resulting in worse outcomes by delaying emergency care.”