We’re at War- Time to Reconsider Everything- A Conversation with Neil Carpenter

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Systems are going to fail by location related to virus penetration, age of the population and ICU capacity.

We need to think about total capacity. We have limited resources. We should prioritize beds and people.Untapped resources- military hospitals, ex-healthcare workers should be activated.

People are going to have to flex their scope of practice- rather than be the best, be good enough in a time of crisis.

Rules, legislative boundaries at the federal, state and hospital level need to be challenged.

Neil can be reached at

https://www.linkedin.com/in/neil-carpenter-924a40/

A link to his calculator can be found at

https://www.linkedin.com/pulse/array-advisors-model-validates-fears-icu-bed-shortage-neil-carpenter/

This is Alan Pitt. I’m here with Healthcare Pittstop. Regrettably, we’re all faced with a new plague across this nation, the COVID virus. I’m here with a good friend, Neil Carpenter. Neil has been a healthcare executive for many years and recently published a model designed help hospitals understand how their resources may need to be re-allocated. Neil, thank you so much for joining me on short notice.

Thank you Alan. People like me are putting together models, but people like you are actually taking care of real patients in a real crisis. So, kudos to all our frontline caregivers all over the country.

AP- I appreciate that Neil but we’re all just trying to do our part. Neil, let me ask a little bit about this model. It was a little bit scary frankly. It looked at how many ICU beds I have in a particular region, it looked at the COVID penetration, and it looked at the age of the population, and this was from available hospital data across the country. Is that correct?

NC- That’s exactly right. I had seen a lot of models out there that just acted like all patients all over the country would get sick once and then the number of beds across the country would be the same. That’s just not true. And so I wanted to break it down and be that as much of a granular level as I could- how many people would get sick where and how many beds they could actually get where. And admittedly, beds are not the only resource issues at hand but they’re critical. If you’ve got a critically old patient, you really want an ICU bed for them.

AP- I gathered from looking at your model it’s customizable. If I don’t agree with your assumptions based on national data and I have other local issues that I can customize this for myself, is that correct?

NC- Correct. We wanted to give this away for free. It’s Excel, it’s on our website you can download it and change assumptions. Not only may you disagree with my utilization assumptions or average days in an ideal assumption but we’re still learning a lot about this disease. We may learn as this progresses, people are in the ICU longer or shorter than we think, or the rate of hospitalization for some of the older populations is more or less than what we thought before. We really had somewhat decent data from both Italy and China, but in the US based population, we haven’t had a lot of data points.

AP- Neil, I regret I didn’t introduce you to the audience, but just briefly, your background with LifeBridge and others.

NC- I am a healthcare consultant and I also was in charge of strategic planning, technology innovation, oncology and a few other things for a two billion dollar health system in Maryland.

AP- Now you’re with Array Advisors out of the DC area and people can find you, of course, on LinkedIn. So I’ll give a link to that.

NC- Exactly.

AP- You basically looked at availability of ventilator by region, by age of the population, by penetration of COVID and you saw a wave coming across the country in terms of when ventilators would not be available, is that correct?

NC- It’s actually ICU bed. I don’t have a ventilator count and in fact, I’m not sure, but I heard the ventilator count is in fact classified as being a little insane. So the sad part is, I don’t think anybody knows how many ventilators are out there. There have been data calls at an initial state or regional level but it was really around ICU beds, medical-surgical beds at the beginning of capacity planning. We hopefully can obtain ventilator data; we’d love to incorporate that into our model.

AP- That would be awesome to be honest. And what was the most surprising thing you found in this data?

NC- Where the red (shortage) is. We got a heat map on our website based on at least the COVID numbers from yesterday though this is obviously changing every day. The most surprising thing is you’d expect Washington state to be red. We anticipate they might be running out of ICU beds in less than two weeks. But actually what’s surprising was the states were top on the list- in New England of all places. We’ve heard about the outbreak in Massachusetts. While we may think about the great academic medical centers up in the New England area, about Brigham and Mass General and Dartmouth, it doesn’t mean they have a lot beds. They also, New England have an older population. Vermont was really high on our list for example. So I think we’re going to see some waves in places that you may not anticipated. And the reason why that matters is, we need at least in my opinion, a much stronger federal response that helps marshal new resources whether it’s military resources, Veteran Affairs resources and lots of other things. And so, we need to know the sequencing of resource allocation that you just talked about because we’re going to need to bring an army to fight but we need to know where that army is going to to go first.

AP- Interesting. So it’s not a general problem, it’s going to be very specific based on the population that you have as well as the resources available to you.

NC- Exactly

AP- You mentioned the VA and other things like that. The VA has large hospitals, I trained in one of those hospitals years and years ago. Do you have any solutions about using some resources we currently have?

NC- They’ve been transforming the VA. Before I went to work with a health system in Maryland, I actually spent time as a consultant on the military healthcare system side. I was in a lot of empty hospitals over the years. They weren’t really empty, but they were vastly underutilized compared to what existed in the larger population. Both the VA and military hospitals, I think at least as of recently, have a lot of spare capacity or capacity could be brought back online. We need to think about this as not a Common Spirit or an Arizona problem, but a national problem, for which we can leverage every available bed at every site of care.

NC- I’m sure there’s going to be legal, regulatory, and financial issues related to  suddenly taking commercially insured patients to a VA hospital, but we have to solve these issues now. That’s just part of the response. The VA military healthcare system is just one example of a solution. There are other solutions? We can defer elective surgery and other elective activity just like we’re doing on the “commercial side” in the VA and military healthcare system to create capacity.

AP- Fascinating.

NC-Everything needs to be about creating total capacity but there needs to be a prioritization of where we’re trying to create it because if we try to bring everything online at once, I think we might be less successful.

AP-I don’t know if you saw, but this morning but the Trump administration announced physicians should be able to take care of people across state lines through telemedicine. That’s one example of how we’re changing regulations in near real time. Historically there have been things we can do and things were allowed to do. We need to get rid of the things that are blocking us from saving lives. I think that’s a major priority we need to get done.

NC-Alan, I agree with you 100%. If I could add one story. I had the privilege when I was working with the military to work with medics who dealt with battle field amputations but because they had no licensing they weren’t allowed to touch a real patient in a meaningful way in the US. We need to push the envelope. Do we need to look at literally calling up people who have medic type training, which are in the tens of thousands, of the military system? Some might be manager’s in a Office Depot, or a warehouse worker. Potentially we could pull these people up.

NC-In lower field positions, because we’ve got to think through how we bring a lot more people to the fight in a way that’s only the military had to deal with before.

AP- Really interesting, actually, we got a memo from the hospital asking retired physicians if they would be willing to come back to the workforce. And I think you’re hitting it at the other direction, the lesser skilled person who we desperately need right now, and how do we activate them and bring them at this time of crisis, how do we flex if you will?

NC- There’s tens of thousands of those people available. In Arizona, they’re going to have a lot of retired physicians. But still the question is, is you’re not going to have potentially tens of thousands of those people.

AP-I as a radiologist I’m not that valuable. A lot of those medics you mentioned are probably much more valuable than I am My hospital system is grappling with, if we cancel elective things, should we do it in a phased approach. Have you seen anything about re-allocating those resources?

NC- I hit the panic button a week ago. I’m no longer am a hospital administrator, but I’ve been in those shoes, I know how hard it is to cancel elective surgery. You’re in Arizona. There’s a lot of older folks there who have real medical needs, but my view of this is simple. It’s not just about freeing up beds, it’s about freeing up staff energy. Right, because eventually there will be a lot of people needing to work 80 hour weeks. It’s going to feel like 80 hour days. To do this successfully, I want to take cardiac patients who you also could potentially treat medically rather than surgically. There’s a lot of debate in the literature about the best course of action. Push people medically, taking some risks so those nurses can rest now, even if they’re not needed now. We send them home for a week. Let them rest, let them be with their family, because they may not see them very much for weeks on end and everybody knows in a war you gotta rest some of the troops. And so everyone should either be resting or providing mission critical care- not really wasting time if it’s not either of those two things.

AP-Fascinating. There’s a lot of downstream effects of this. So what if you might need cancer surgery, but if you’re going to be in the ICU for two weeks afterwards with bowel problems, maybe you delay that until the resources are available. Providers may have to think through those decisions.

NC- There are infection issues? As a patient, I would not want to be in the hospital because COVID is there. If the patient gets infected are they going to  have a bad outcome? It’s not a one-step risk calculation? It’s actually a multi-factorial risk calculation that’s going to evolve over time.

AP-Do you believe that this is going to change our healthcare delivery system long-term?

NC- I hope so. Currently, we finely tune our healthcare system to do a bunch of things, and this  (public health) isn’t one of them. I think we need to pull back a little around capacity and about flexibility in a way that we haven’t. We’ve almost been like this beautiful, beautiful device that can do a few things but suddenly you try to… It’s like some kind of sports car. Suddenly you’ve got pack in to move and you can’t fit anything in it. Because it was designed to drive 150 miles an hour and turn on a dime. And suddenly we’ve got to pack your grandparent’s house inside. It doesn’t work.

AP- We’ve built the Maserati of healthcare as opposed to the Honda that can service the most people and get the most value.

NC- Correct. We’re going to have real tough trade off around training some people and investing. We have the best of the best care for some relatively narrow conditions versus flexibility in the course of a pandemic. I think what’s going to be a great example on this is we’re going to be taking incredible interventionist, and they’re going to be hospitalists pretty soon. We’re going to need them to flex which is one of the reasons to ask them to rest right now, but we’re also going to have to rethink the total social utility of that.

AP- Do you think we have the makeup to do that, to make the hard choices away from where we make our money today to where we should be tomorrow for national health care delivery?

NC- I think the question is how many people die? Honestly, Allen. And I think sadly, the more people die, the more likely we will be to ask those questions.

AP- I was talking to some friends and they said, “my grandparents used to talk about people died during the flu epidemic.” And we haven’t lived through that. I wonder if this is going to be something that changes our psyche in the way we look at things long term.

NC- I think we’ve been a country of abundance. And we’re about to not be for a little while.

AP-How do I best get our hospital leadership to take what you’ve put together and put that into action? Any thoughts around that?

NC- Well, I think we did the mapping. And we did this to help spur debate and discussion about what to do- both on a policy level and a local level. So, what I encourage folks to do is plan out your shortages. A lot of hospitals are doing this around beds, and talk through how you’re going to flex and take more dramatic measures. And things are financially tangible. There are a lot of physicians who are saying, “I’m not going to take… ” there is going to be internal resistance. Staff is going to have to do things they may not be comfortable doing. Things they haven’t done since they were resident. You understand all those conversations. It will be rough. And so, I’m putting these models together forward. And I hope more people do the same to force those conversations earlier rather than force them in the middle of the night when you have to re-purpose a physician

AP-  One of the things that we always juggle in healthcare is what’s good for me, and what’s good for the patient, and what’s good for society. And a lot of that regrettably, gets back to some issues of liability. I may not trust in this particular care transition, whatever we’re going to do. And I may be personally exposed to liability in doing so. I wonder if we’re going to see some relaxation of liability in this time of need, where there’s a national emergency.

NC- That’s a great point. We should actually be proactively waving lability now, just to take this all off the table. Just like the way that we did about payment of health, we took it off the table, which should take liability of health off the table. We should take scope of practice rolls off the table. These are often things that have to happen in at the state level legally. To be taken off just off the table in part helps spur those discussions. Asking, “should we waive all scope of practice laws?”

AP- I think what you have to do is presume that someone’s acting in the patient’s best interest at all times. I’ve been asked as an expert witness. I’m pretty reluctant to testify against a physician unless they clearly stepped out of bounds. They took a risk with a patient and didn’t disclose. If they showed up drunk. Generally my assumption is a healthcare provider is working in the best interest of the patient. And sometimes things go wrong. This is a really odd circumstance where people are going to have to act out of their usual scope of comfort.

NC- Things that are going to be tough for people who are really good at what they do, to say the world doesn’t need me to be really good at what I do. They need me to be to be acceptable at doing something different.

AP-That’s really fascinating. Neil, I wanna thank you for your time with everything that’s out there in the media. I wanna keep this relatively short. People can reach out to you again on LinkedIn. Any other ways that you’d like them to communicate if they want to hear more about your model.

NC- No, call me, text me, contact me on LinkedIn. I’m happy to share anything I have. And you’re welcome to do whatever you want with it, as long as it helps to make the world a better place.

AP- Thank you so much for your time.

NC- Thank you.

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