[Editor's Note: This is the conclusion of a two-part series of articles on the GRMC Board meeting on 032720.]
By Mary Alice Murphy
The previous article on the Gila Regional Medical Center Board of Trustees virtual meeting on Friday, March 27, 2020, can and should be read before this article at https://www.grantcountybeat.com/news/news-articles/56969-grmc-board-of-trustees-hear-preparations-for-covid-19-032720-part-1
After Chief Quality and Compliance Officer Tanya Carroccio completed her report, Interim Chief Executive Officer Richard Stokes said he wanted to point out how instrumental two people have been to the continuing work of Gila Regional to be prepared for a potential surge of COVID-19 cases. They are infection specialists, Dr. Tsering Sherpa and William Hemmer.
Chief Nursing Officer Kelly Rodriguez said her department has been looking at processes internally and things to be taken into consideration are the so-called "clean and dirty patients, which are the general patients and those who may be experiencing symptoms of the virus. We are looking at the structure of the facility, how many beds, where they are and whether we have enough, and do we have enough medications and equipment supplies overall, as well as for the bedside. We have staffing that belong to specific departments, as well as ancillary staff that could be utilized at bedside. We have changed processes on how respiratory patients are being treated. When we have a surge, we will separate them from the patients without respiratory symptoms. We will have separate triage processes for those with respiratory issues. We have talked about increasing beds in the ICU (intensive care unit), where we can have 10 beds and add beds from Med surg pod 2 to form the COVID area. Med Surg 1 will be for everyone else. Labor and delivery will be on the opposite side of the hospital, where they are now. The Med Surg 2 will be on a separate air handler, and we will pre-op surgical patients in the PACU (post-anesthesia care unit) where they will be returned after surgery. Clean patients (non-respiratory symptoms) will move to the Cancer Center. In phase 2, the Pyxis med-stations will move where needed. We have a team of 10 people still working on the processes. If we find we are reaching a threshold, we will start moving to the next phase."
Stokes said: "I thank the willingness of our staff and the attitude people are taking toward doing all this. It makes Gila Regional proud and serves the community well."
Chairman Tony Trujillo said the staff's No. 1 concern is potential furloughs.
Stokes, reporting as Chief Financial Officer, said cash flow is a problem. "We have had a significant reduction month-to-date. We are protecting our local staff, the natives and those who live here. We are making some changes. We are excited about Kelly coming on board in the CNO position."
"So as not to have to have a furlough situation," Stokes said, "we are looking at grant opportunities. We are also looking at the stimulus plans for opportunities. I asked for acceleration or on-time payment of the expected safety net care pool state funding. Our billing company is doing a wonderful job, which should help the revenue stream."
Trujillo said: "We still have employees who don't want to come here out of fear of what's going to happen."
Stokes said that was the reason stated for a couple of resignations this week (one of whom was the former CNO, who took another job).
"Health care, at its core, can be risky," Stokes said. "We've given all our staff N95 masks and soon we will have cloth ones to go over the N95 masks to increase the time they can be used. We are blessed at this moment not to have any cases, but that will change."
Trujillo said he understands the number of tests is a challenge.
"We have done, as of yesterday, 87 tests," Stokes said. "Other than the 57 that we received negative results on, we are waiting on the remainder. The issue we have is that we have a limited number of tests, about 200, so we are testing only when the symptoms resemble COVID. If we can get the supplies to analyze the tests, we can get results in 45 minutes. We have the lab capability here."
Trujillo asked Stokes to expand on what the plans are for a COVID clinic.
"We started contemplating it early this week," Stokes said. "We want a clinic for people to go to if they have symptoms of COVID, instead of going to their primary health clinic where they can expose others to it. We asked permission of the state. They had questions and criteria we would have to meet. If we meet all the criteria, we will do the tests at the separate clinic. We are also trying to figure out how to work together with Hidalgo Medical Services and Gila Regional. We have hurdles, so we sent a letter of intent to the New Mexico Department of Health. We had a meeting with HMS and we both want to do it, but we have to sort out how we can do it from a regulatory perspective. We just today got clearance to open the clinic across the road under Dr. John Stanley for the COVID testing."
Trujillo said Stokes had reported a negative cash flow and the impacts.
"From a revenue perspective, we have received an estimated $1.5 million less in March than in February," Stokes said. "In 45 days, we will hit the wall. We have to be aware that cash will slow down. That's why we're trying for grants and stimulus funding. From the cash flow perspective, we will pay payroll first. We are working with our vendors who have been understanding and will let us pay a little at a time."
He said the request for critical access designation has been submitted. "Congresswoman Xochi Torres Small gave us the steps to do it. The anticipated date was Aug. 1. But the effective date will be when we can get accreditation of the hospital as being appropriate for critical care."
Trujillo said, on the stimulus package, he and Stokes have been in constant, almost daily contact with Melanie Goodman of Sen. Tom Udall's office on "what we need to do to tap into the funding. We have a team to do that. Goodman has been talking about trying to expedite the critical access process. Sen. Martin Heinrich has also been in contact with the Dallas office to help expedite the critical access designation. We are also pushing to get the safety net care pool funding early."
"Do we have any other discussion on the COVID and finance issues, before we open it up to the rest of the business on the agenda?" Trujillo asked the members. "We encourage the public to ask questions. I urge you to call Richard, Tanya or Kelly for answers. Don't hesitate to ask the questions. We want to set the record straight."
Trustee Jeannie Miller had questions about elective surgery, since it has been curtailed for the time being. "Can that staff go into other sections of the hospital?"
Rodriguez said: "Yes, and we are also looking at other staff, such as the critical care staff. We are trying to reallocate staff if we get to the surge plan."
"We have a wealth of experience within this board," Miller noted. "If we can help, let us know and call on us."
Trustee Ed Wilmot asked for an expansion on the staged response plan.
"Beyond the 10 bed ICU expansion, we have a plan for six more ICU beds," Rodriguez replied. "Then, beyond that we will move the ventilated patients into Med Surg 2. We will tap into our Hometown Oxygen vendor and get 10 Trilogy (ventilator) units, which don't need air gas, but operate on their own. We will use the regular ventilators in the ICU where we have the availability of air gas. So, we could potentially go up to 16 ventilated beds. Beyond that, we could use four to five anesthesia machines and clean them. We have to keep some for emergency surgery. So with five anesthesia machines and the three EMS ventilators, we have the capacity for up to 26 ventilators. Then we get into the staffing component. So, we're getting into how many ventilators can one person manage? And remember they are doing it 24 hours a day. We are looking heavily at that number as well."
Wilmot asked if the hospital has adequate PPE.
"We will constantly evaluate that," Rodriguez said.
"My biggest concern," Wilmot said, "is with the low rates, none, we have now, will we see the problem of priority allocation. Is that a problem?"
Carroccio said: "We did get started early enough on that so, we feel better prepared than some of the other hospitals we hear about. But we don't know until we see the surge. We can order and we have ordered, and it's back ordered. I'm very happy with our infectious disease personnel and our purchasing department for stepping up early. We're hoping to be able to get in when the state can get supplies. On the call we had with the governor she was very interested in the issue. And it sounded like she was willing to get the Department of Health to handle any surplus and get them where they are needed. That's what other states have done when they are stockpiled."
Stokes interrupted the meeting to report he had just gotten notification that "DOH has approved our temporary COVID clinic permit."
Miller asked if Fort Bayard Medical Center could be of help to the hospital.
Rodriguez said that even on a normal basis, Fort Bayard Medical Center is at capacity. "We sometimes can't get people into there, so I'm not sure it's an option."
Stokes also said that through Dr. Ratliff and Heinrich's office, they are working for funding for Gila Regional and UNM Hospital on how to get access to funding.
Trustee James Marshall said that DOH has put out a notice that any surpluses or sharing of items between hospitals have to go through them, and the state then sends the items to the appropriate agency that needs or requests them.
Stokes concurred that the state did send out a letter to all health care providers that "we have to report our PPE levels to the state. On Tuesday, we heard that Mountain View Hospital, where we often send our patients that require more care than we can offer, only had 65 masks. We transferred 160 masks to them and then we received a letter from the state not to do that."
Trustee Joel Schram said he saw some statistics that indicated an estimation of a peak in New Mexico on or around April 24, with a potential of 513 deaths at 1.4 percent based on 1,150 patients a day."
Trujillo said: "We can't know what the surge will look like. We are planning for the worst."
With no more discussion, the meeting went to new business.
The first item was a third contract amendment extension to Dialysis Clinic Inc. from March 1 for two years, with the possibility of a renewal of another year. The amendment had an updated price list.
Wilmot thanked Tanya "and crew for answering all my questions on this last night."
The trustees approved the contract amendment.
The second item was renewal of the contract with the Innova Emergency Department Physician Group. Carroccio said: "This is our emergency medicine contract good for two years. It cannot be automatically renewed, but it is subject to negotiation for renewal."
Schram said he believes it might reduce the hospital expenses. Stokes clarified that it will be an increase in dollar cost, but it includes performance requirements.
Carroccio said the increase was for cost of living. "The way the contract is set up, as required by CMS (Centers for Medicare and Medicaid) and the Joint Commission, we have performance measures to monitor, so it was a little more difficult to negotiate, because these specifics had to be in the contract."
It was approved.
The third item was to name Dr. Brian J. Robinson as temporary Anesthesia Medical Director. Carroccio said it was a professional services contract. Dr. Lawyer has been taking care of it. Robinson agreed to cover during the time until the hospital gets a new contract set in place.
Trustee Cynthia Moreno asked why Dr. Dalton could not cover it. Trustee Dr. Victor Nwachuku explained that the position required a physician who is at the hospital all the time. "Dr. Dalton is not always here."
Carroccio said: "Essentially CMS requires a physician board certified in anesthesia or a surgeon. Robinson meets those requirements."
Moreno asked since it was for a short time, who would oversee the position.
"Dr. Kotch (emergency department director) will provide the monitoring," Carroccio said.
The contract was approved.
Trustees discussed sending a joint letter to Sens. Tom Udall and Martin Heinrich to ask for their support with expediting the designation of critical access hospital for Gila Regional Medical Center.
Marshall said he has worked with Melanie Goodman for probably 20 years. "In our conversation about Gila Regional filing for critical access, I told her it was an informed decision by the hospital, and I asked her if she could get in touch with Tony and Richard. At that time, I felt it was critical and that we were ready. I think we should get this letter off to them. I also think we should only have the signatures of the chairman and the CEO required. It's not necessary to have all our signatures. So, I move that we send the letter, but I want to amend it to require only the CEO's and chairman's signatures required."
The amendment was approved and the sending of the letter was approved.
Dr. Nwachuku said he had a call from Lt. Gov. Howie Morales requesting a letter for the hospital asking to get the safety net care pool paid early. "He asked for a letter from us, but he has already written a letter. I will drop off the letter to Richard."
On the credentialing report, it was noted there is one new applicant for appointment and that a nurse practitioner that resigned had been incorrectly listed as a physician.
Wilmot asked if there were a red flag report this month and the reply was there was none.
The credentialing report was approved.
Wilmot said he felt a significant need for the board to meet in closed session, even if virtually. "I am concerned there are issues we need to address as soon as possible."
Trujillo said he had concerns as to whether they could do a closed session virtually. "But I have been assured that it is possible. We are aiming at Wednesday or Thursday so we can advertise it. I am also bothered that this time we could not include public comment. I'm hoping we can do that before the closed session. I think it's important to hear the public's concerns. I'll work with Richard to make it happen next week."
Stokes said: "Things are happening quickly. We did get approval for the clinic across the street, and we are ready to occupy it."
Miller said: "I am blown away by what we are doing to keep our heads above water."
"I'm also impressed," Wilmot said. "We have a fabulous team here. I'm looking forward to the session next week."
Trujillo thanked Kelly Rodriguez for filling the CNO position gap.
Schram also thanked the team from Cisco for facilitating the virtual session.
The board of trustees adjourned.