10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) Tarryn Mento RE: Questions about triggers (Response requested by Tuesday at noon) 1 message Sweeney, Sarah Thu, Oct 1, 2020 at 5:19 PM To: Tarryn Mento Cc: "Workman, Michael E" , "Sturak, Craig" Here are several more answers. I will send the others as soon as they are available. ------ A Scripps representative said the county received input from hospitals on which metrics should be included in our triggers and they recommended the PPE metric include not just gowns, gloves, but also pharmaceuticals and other critical supplies. Please share all the items that are included in the PPE metric and how you crunch those multiple numbers to reach the one figure reported on the trigger dashboard. During a conference call with hospitals CEOs, the suggestion was to increase the types of supplies that we tracked as it relates to a county-based trigger. Later in the call, they determined that compiling and reporting that information multiple times each week would not be tenable. The County decided to track the items we do, as reports on these supplies were already being made multiple times each week. It is not a perfect formula but we count the number of hospitals that have at least x(either > 2 weeks or > 3 weeks) number of days on hand of each item and divide that by the total number of hospitals reporting. That gives us the percent of hospitals with at least x number of days on hand of the PPE item. Then we take the average of the percent, again not perfect but it paints an accurate picture, for the overall percentage of hospitals with Days on Hand for the total PPE. The reason this is not perfect is that if, for example, we are out of gloves, it does not matter how many days on hand of simple surgical masks they have, as procedures and exams cannot take place without gloves. This metric is to assess the overall health of the supply chain and tracking allows us to focus in on specific areas or facilities that need assistance. Dimitrios Alexiou at HASDIC said the county may count licensed beds for its hospital and ICU capacity metrics, but that doesn’t accurately represent the number of beds that are staffed for immediate use. Please explain what types of beds the ICU and hospital capacity triggers do track and why that is. You will note from our press slides that both the licensed ICU and physical ICU beds are reported. Both are tracked—the number of licensed beds reflects potential capacity (ie the local ability to stand up to that level) and the physical beds number indicates what is currently available. I understand that hospitals are concerned about staffing, especially ICU staff, but staffing is not tracked by the county on its trigger dashboard. Why is that? CDPH monitors and mandates staffing levels. We work with hospitals in monitoring this data, but have no authority to mandate staffing levels. https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 1/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) Alexiou also mentioned that once a hospitalized COVID patient tests negative for the virus, they are no longer considered a hospitalization, but some may still be hospitalized for the illness and taking up a bed. Can you confirm this? If so, please explain why this is. Not sure what the context of this was, so may not fully understand the question. I can confirm that we account for all hospitalized patients and, in a separate category, account for all patients hospitalized for COVID. In other words, both are tracked. I have learned that since the beginning of the pandemic, hospitals are less reliant on ventilators as an early method to treat COVID patients but some other supplies have become unexpectedly critical during the pandemic, such as dialysis and ECMO resources. Can you verify that the pandemic has put additional pressure on these resources? If so, are you tracking these or have any plan to track these as a trigger? In regard to ECMO, there are indications that there has been additional pressure on resources, but we actively monitor ECMO criteria to identify concerns and solutions when needed. Like ECMO, dialysis resources are also monitored and we work with entities throughout the county and state to facilitate collaboration and identify concerns and solutions. Sarah Sweeney, MA, Communications Officer Agency Executive Office County of San Diego Health & Human Services Agency O: 619-685-2522 C: 619-997-6481   For local information and daily updates on COVID-19, please visit sandiegocounty.gov/coronavirus. To receive updates via text, send COSD COVID19 to 468311.   From: Sweeney, Sarah Sent: Thursday, October 1, 2020 12:38 PM To: 'Tarryn Mento' Cc: Workman, Michael E ; Sturak, Craig Subject: RE: Questions about triggers (Response requested by Tuesday at noon) Hi Tarryn, We are making progress on gathering the information for the outstanding questions, but they aren’t complete. These questions often require input from multiple sources, all of whom are currently focused on COVID response. They should be complete and ready for you soon. https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 2/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) In regard to the clarification, I am not sure I understand your email. If I understand correctly, it looks like we need to clarify that we get information from Resource Bridge. The original response was just pointing to the distinction that there is more than one system and that Resource Bridge has data points beyond just lab results. Sarah Sweeney, MA, Communications Officer Agency Executive Office County of San Diego Health & Human Services Agency O: 619-685-2522 C: 619-997-6481   For local information and daily updates on COVID-19, please visit sandiegocounty.gov/coronavirus. To receive updates via text, send COSD COVID19 to 468311.   From: Tarryn Mento Sent: Thursday, October 1, 2020 9:37 AM To: Sweeney, Sarah Cc: Workman, Michael E ; Sturak, Craig Subject: Re: Questions about triggers (Response requested by Tuesday at noon) Hi all, Still waiting on the remaining response. But follow up to this response. You said that hospitals reporting through Resource Bridge is "entirely separate data points," but after speaking with them and reviewing the county's website that says more generally "health care providers" are required to report cases of coronavirus, I understand they also report positives results and total tests conducted on a daily basis (among a number of other data points), which helps inform the county's case and positivity rate calculations. Please confirm this by noon today. 5. Further, it seems that there are at least three ways for entities to electronically report (SD Health Connect, Resource Bridge and CalREDIE). Please clarify which entities (lab, health care provider, other, etc.) use which system to report COVID results and other COVID data you use for the trigger dashboard and why that is. Do some entities report through more than one system? https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 3/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) Local hospital labs submit electronic laboratory data via SDHC. Reference labs and labs in other counties submit electronic laboratory data to CalREDIE. Results from both of these systems are routed into our disease registry and are represented in our case and lab testing metrics. Hospitals also report to Resource Bridge, note that this is not lab result reporting, but entirely separate data points. On Tue, Sep 29, 2020 at 5:07 PM Sweeney, Sarah wrote: Hi Tarryn, 1. As I understand, labs report testing to you daily, they then share that information with the health providers that ordered the tests and those health care providers also report testing data back to you. The statewide glitch that was reported in August shows some of the daily testing information is received through the state. And I understand some facilities report through the HIE San Diego Health Connect. How do you ensure the accuracy of this information if it is being reported to you multiple times from multiple entities and in multiple formats (fax, phone, email, web-based systems, etc.)? Our intake team searches our database for existing cases before entering new reports; if the record already exists, the information is attached to the existing record. Sometimes duplicates do slip through, but we also do routine duplicate checks using a data processing program and staff review and make corrections as needed. 2. Which entities are reporting testing information only through the state and how do you receive it from the state on a daily basis? Many commercial or reference labs (e.g., Quest, LabCorp, ARUP, LGC/PrivaPath, Bioreference Labs) are national labs and report directly to the state via electronic laboratory reporting rather than have interfaces with multiple jurisdictions. When the lab reports (in the form of HL7 messages) come into the state system, they are automatically processed and messages with San Diego zip codes are routed to our system electronically. 3. I see on your website that health care providers must report all positive coronavirus tests to the county and the instructions say “to report a communicable disease, you may contact the Epidemiology Unit by phone,” but hospitals have told me they report via Resource Bridge. Please explain the volume of healthcare providers that are reporting results by phone, Resource Bridge or another method. These are two different things. Resource Bridge is how hospitals report current COVID patients, resources, etc. All providers are required to report diagnosed communicable diseases to EISB (or TB or HSHB). Mostly we receive these by fax; some urgent diseases require a phone call. 4. I see labs are required to report electronically through the state, but those that can’t must use fax and email. Why are some labs, like Helix, not able to report electronically and how many (estimates are acceptable) labs that report COVID test results are reporting via fax and email? Many of the labs now reporting COVID results were not testing for communicable diseases previously and had no experience with reporting or have systems set up to do so. To report electronically, they need to have the ability to generate HL7 messages and many cannot. Most hospitals contract with a third-party vendor for a laboratory information system that can do so. The labs need to devote the resources to this. Over 100 labs are sending csv files to CDPH. Some of these also report to San Diego, many don’t typically test San Diego residents. Many out of state labs who don’t typically test California residents will send us faxes. 5. Further, it seems that there are at least three ways for entities to electronically report (SD Health Connect, Resource Bridge and CalREDIE). Please clarify which entities (lab, health care provider, other, etc.) use which system to report COVID results and other COVID data you use for the trigger dashboard and why that is. Do some entities report through more than one system? Local hospital labs submit electronic laboratory data via SDHC. Reference labs and labs in other counties submit electronic laboratory data to CalREDIE. Results from both of these systems are routed into our disease https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 4/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) registry and are represented in our case and lab testing metrics. Hospitals also report to Resource Bridge, note that this is not lab result reporting, but entirely separate data points. 6. What other entities — such as insurance companies or foreign entities that may test a San Diego resident — report testing information to you besides those that I have listed? Don’t think we’ve seen any reports from insurance companies or foreign entities. Mostly we get reports from labs, hospitals, providers, clinics, SNFs. Our website lists who should report according to Title 17 Sections 2500, 2505, and 2508. We do get reports routed from other counties and other states. 7. Are all tests conducted and results based on nasal swabs? If not, what are the other types of tests you include in your daily tallies/case rate? How do you tally and report results from FDA-approved serological tests? At this time, we do not include serologic test results in our case counts, so the tests we are counting would be based on nasal or nasopharyngeal swabs. 8. What does the county do with an indeterminate result and how do those results factor into our case and positivity rates? Indeterminate results are not positive results. We only count positive results as cases. 9. Dr. Wilma Wooten previously stated that the county was re-considering the community outbreak threshold. What is the status of that? This is still under review. As you are likely aware, San Diego County is one of the few counties throughout the state reporting more than the handful of metrics the state determined. The outbreak metrics is one example of the above and beyond what the state requires surveillance we are currently doing locally. When this metric was set at 7, it was based on the average number of outbreaks at the time. At that point, a stay at home order was in place and there was much less mingling of different households. With the lifting of stay at home orders and in increase in activities that involve those from various households, a new look at the threshold is still under consideration. ---------- 18. An audience member told me that a 2-1-1 representative said the county was not conducting any case investigation for individual positives, only those believed to be linked to a potential outbreak — is that accurate? Why or why not? This is not accurate. We make an effort to investigate all persons who test positive. At present, fewer that 5 percent of all cases are associated with an outbreak. Case investigation is integral to both contact tracing and allowing us to identify the locations that people have in common that ultimately are confirmed as outbreaks. 19. On the trigger dashboard, the percentage of temporary shelter available for those experiencing homelessness has very rarely, if ever, changed, even though speaking to officials at the Convention Center, bed totals there have fluctuated. Why has this metric not changed? The trigger for the homeless population is “Temporary shelter available for less than 15% of homeless population.” We calculate it by dividing the total number of rooms/beds by the homeless count. The metric (currently at 38%) has not changed much over time because the total number of rooms/beds has not https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 5/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) changed as frequently as the other metrics do. There have only been a few days when it was reported to us that the total number of rooms/beds changed. As a reminder, the convention center is one of several options for shelter—we also have public health hotel beds, RTFH beds and Encinitas beds. Sarah Sweeney, MA, Communications Officer Agency Executive Office County of San Diego Health & Human Services Agency O: 619-685-2522 C: 619-997-6481   For local information and daily updates on COVID-19, please visit sandiegocounty.gov/coronavirus. To receive updates via text, send COSD COVID19 to 468311.   From: Workman, Michael E Sent: Tuesday, September 29, 2020 4:36 PM To: Tarryn Mento ; Sweeney, Sarah Cc: Sturak, Craig Subject: RE: Questions about triggers (Response requested by Tuesday at noon) Should have something soon. Didn’t get all of it. From: Tarryn Mento Sent: Tuesday, September 29, 2020 4:30 PM To: Sweeney, Sarah Cc: Workman, Michael E ; Sturak, Craig Subject: Re: Questions about triggers (Response requested by Tuesday at noon) Hi all, https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 6/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) Checking in on this. On Mon, Sep 28, 2020 at 9:36 AM Sweeney, Sarah wrote: Good morning, Tarryn. Confirming we received these and will our best to address them by your deadline. Sarah Sweeney, MA, Communications Officer Agency Executive Office County of San Diego Health & Human Services Agency O: 619-685-2522 C: 619-997-6481   For local information and daily updates on COVID-19, please visit sandiegocounty.gov/coronavirus. To receive updates via text, send COSD COVID19 to 468311.   From: Tarryn Mento Sent: Monday, September 28, 2020 9:07 AM To: Workman, Michael E Cc: Sturak, Craig ; Sweeney, Sarah Subject: Re: Questions about triggers (Response requested by Tuesday at noon) I wanted to confirm that this was received. I didn't hear back on Friday so please let me know. CC'ing Craig and Sarah to make sure this was seen. Thanks! https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 7/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) On Fri, Sep 25, 2020 at 12:10 PM Tarryn Mento wrote: Hi Mike, Here are the questions I have about the county's data that informs its 13 triggers. I'm asking for responses by Tuesday, Sept. 29 at noon. As you can see, I tried to be very specific. Please call me if you would like to discuss this. My cell is 315-345-1313. And please feel free to provide any further comments that you think is important for the public to know about this data. 1. As I understand, labs report testing to you daily, they then share that information with the health providers that ordered the tests and those health care providers also report testing data back to you. The statewide glitch that was reported in August shows some of the daily testing information is received through the state. And I understand some facilities report through the HIE San Diego Health Connect. How do you ensure the accuracy of this information if it is being reported to you multiple times from multiple entities and in multiple formats (fax, phone, email, web-based systems, etc.)? 2. Which entities are reporting testing information only through the state and how do you receive it from the state on a daily basis? 3. I see on your website that health care providers must report all positive coronavirus tests to the county and the instructions say “to report a communicable disease, you may contact the Epidemiology Unit by phone,” but hospitals have told me they report via Resource Bridge. Please explain the volume of healthcare providers that are reporting results by phone, Resource Bridge or another method. 4. I see labs are required to report electronically through the state, but those that can’t must use fax and email. Why are some labs, like Helix, not able to report electronically and how many (estimates are acceptable) labs that report COVID test results are reporting via fax and email? 5. Further, it seems that there are at least three ways for entities to electronically report (SD Health Connect, Resource Bridge and CalREDIE). Please clarify which entities (lab, health care provider, other, etc.) use which system to report COVID results and other COVID data you use for the trigger dashboard and why that is. Do some entities report through more than one system? 6. What other other entities — such as insurance companies or foreign entities that may test a San Diego resident — report testing information to you besides those that I have listed? 7. Are all tests conducted and results based on nasal swabs? If not, what are the other types of tests you include in your daily tallies/case rate? How do you tally and report results from FDA-approved serological tests? 8. What does the county do with an indeterminate result and how do those results factor into our case and positivity rates? 9. Dr. Wilma Wooten previously stated that the county was re-considering the community outbreak threshold. What is the status of that? 10. I know the definition of a community outbreak, but what epidemiological criteria must be met in order to link cases back to a common location? 11. What data sources do you rely on for ILI and COVID syndromic triggers? Please clearly define what you mean by an “upward trajectory” as the threshold. For example, does this mean if it increases .1% over a day period that this trigger is abnormal? 12. A Scripps representative said the county received input from hospitals on which metrics should be included in our triggers and they recommended the PPE metric include not just gowns, gloves, but also pharmaceuticals and other critical supplies. Please share all the items that are included in the PPE metric and how you crunch those multiple numbers to reach the one figure reported on the trigger dashboard. https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 8/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) 13. Dimitrios Alexiou at HASDIC said the county may count licensed beds for its hospital and ICU capacity metrics, but that doesn’t accurately represent the number of beds that are staffed for immediate use. Please explain what types of beds the ICU and hospital capacity triggers do track and why that is. 14. I understand that hospitals are concerned about staffing, especially ICU staff, but staffing is not tracked by the county on its trigger dashboard. Why is that? 15. Alexiou also mentioned that once a hospitalized COVID patient tests negative for the virus, they are no longer considered a hospitalization, but some may still be hospitalized for the illness and taking up a bed. Can you confirm this? If so, please explain why this is. 16. Speaking with a national expert at Pew Charitable Trusts, health facilities run the risk of mismatching patient records — I’m told per nationwide estimates, an error occurs up to half the time — and the risk is greatest when there are multiple entities sharing records, which is how our COVID test results reporting network operates. What is your error matching rate and what steps are you taking to improve on that? 17. The expert also said that poor patient matching can slow down contact tracing efforts because the various entities that are checking in patients for testing may not accurately capture all necessary contact information. What percentage of positive results reported to the county for case investigation/contact tracing are missing required information (outlined in the California Code of Regulations, Title 17, Section 2505, plus race/ethnicity) and what impact does this have on our case investigation/contact tracing abilities? 18. An audience member told me that a 2-1-1 representative said the county was not conducting any case investigation for individual positives, only those believed to be linked to a potential outbreak — is that accurate? Why or why not? 19. On the trigger dashboard, the percentage of temporary shelter available for those experiencing homelessness has very rarely, if ever, changed, even though speaking to officials at the Convention Center, bed totals there have fluctuated. Why has this metric not changed? 20. I have learned that since the beginning of the pandemic, hospitals are less reliant on ventilators as an early method to treat COVID patients but some other supplies have become unexpectedly critical during the pandemic, such as dialysis and ECMO resources. Can you verify that the pandemic has put additional pressure on these resources? If so, are you tracking these or have any plan to track these as a trigger? -Tarryn Mento KPBS Health Reporter (619) 594-3766 @tbmento https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A16793971846… 9/10 10/15/2020 San Diego State University Mail - RE: Questions about triggers (Response requested by Tuesday at noon) -Tarryn Mento KPBS Health Reporter (619) 594-3766 @tbmento -Tarryn Mento KPBS Health Reporter (619) 594-3766 @tbmento -Tarryn Mento KPBS Health Reporter (619) 594-3766 @tbmento https://mail.google.com/mail/u/0?ik=b196120b9e&view=pt&search=all&permthid=thread-a%3Ar-3590503405194777439%7Cmsg-f%3A1679397184… 10/10