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Scott Webb: With the country reopening, many parents are wondering what to expect at primary care offices and hospitals, and how telehealth may benefit their children. Joining me today to discuss safety protocols at Stanford. Children's Health is Dr. Denny Lund. He's the Elizabeth Wood Dunleavy Professor, Chief Medical Officer and Professor of Surgery at Lucile Packard Children's Hospital, Stanford, and the Associate Dean of the Faculty for Pediatrics and Obstetrics Stanford University School of Medicine. Also joining me is Dr. Grace Lee Associate Chief Medical Officer for Practice Innovation, Professor of Pediatrics at Stanford University School of Medicine, and a Pediatric Infectious Diseases Physician. This special podcast is brought to you by Stanford Children's Health. I'm Scott Webb. So Doctors, thanks so much for joining me today. I'm going to start with you today, Dr. Lund, how have you and your team been evolving care for your patients during the pandemic? What's been happening as far as well, visits and in person visits during this interesting period?

Dr. Lund: So this has been a very uncertain time. And during this COVID pandemic, we initially were instructed by the State and County government, and very honestly just prudence, to decrease our amount of clinical activity to avoid the exposure of patients and healthcare workers to the potential of COVID-19 infection. So we started a process actually of decreasing in person visits and in person, what we consider elective care, fairly drastically. Although I do want to say there's really no elective care in children. We don't do, you know, elective plastic surgery cosmetic surgery in children and things like that. And the things that can be put off safely, like maybe a little bit of a wait to get a vaccination, although vaccination should not be put off indefinitely, was something that we backed away from. That led to about a 60% decrease in the amount of surgical care that we were providing in the hospital.

We continued to do all kinds of urgent and emergent operations, but things that could be scheduled or delayed safely without adversely impacting a child's outcome were delayed. Clearly things have changed now. And we're in the process of now trying to ramp up again. In the meantime, we've done all kinds of work around making sure that we have enough protective personal equipment or PPE for our health caregivers and for patients. And we've also been able to ramp up the amount of testing that we can do, not only for patients and for healthcare workers, because that's important to allow patients to understand that the hospital's a safe place to be. So after about six weeks of reduced medical capacity, we've now started ramping back up inpatient visits. One of the things that we did in the meantime, it's probably one of the good things that will come out of the COVID-19 pandemic is that we've really implemented telehealth very actively.

And we've gone from doing about 25 or 30 telehealth visits a day in our system to doing over 800 a day. And patients have actually found that to be quite reassuring. They can see their Doctors, they can see their Doctors face, and they can get the care they need without having to come long distances or come and be exposed to people in the hospital. So we want to continue to keep that telehealth part of healthcare going strong in the future. But in the meantime, it's now necessary to bring up some of the in person visits again. And we're doing that really with a careful eye on making sure that our healthcare workers have plenty of PPE, our families have PPE, and testing as needed.

Host: So Dr. Lee, as offices open back up, how can a parent not worry about those in person visits? What are the current safety protocols?

Dr. Lee: Just to reiterate what Dr. Lund mentioned, Stanford Children's Health does provide all critical services and all essential services for our patients. So in addition to ensuring that our patients have access to critical procedures that have been delayed or deferred, we want to make sure that our kids also have access to all essential services. And those include things as Dr. Lund mentioned, such as keeping children up to date on their vaccines, managing chronic conditions, such as diabetes, inflammatory bowel disease, and congenital heart disease, and providing necessary care for children with cancer transplants or other immune compromised patients. In addition, we have a really wonderful obstetric service, and we're continuing to ensure that the moms who deliver here at Stanford Children's Health are cared for in the highest quality manner as well as in the safest way possible. And we really do have very few elective services. So you asked about how appearance can not worry about an in person visit.

I would say that safe healthcare has been so important to Stanford Children's Health overall, from very early on we've implemented protocols to ensure the safety of our patients, our families, our providers, and our staff. Just a few examples of how we keep our facilities safe. We do routine symptom screening of all patients and family members before coming in and routine symptom screening of all healthcare providers and staff working in our facilities. We've had visitor restrictions in place in order to ensure that we're you know, minimizing exposure to individuals, both for our families and patients, as well as our providers and staff in order to prevent that spread within the facility, we of course recommend universal masking for all of our providers and our patients as Dr. Lund had mentioned, and this predated the County ordered to start universal masking in the community. Telerounding and telehealth visits have been hugely helpful. And it has been a really wonderful addition to the way we deliver care.

We have already in the past been doing a substantial portion of telehealth visits, and I would say Stanford Children's Health has been at the forefront of that, but this really just enabled our ability to implement and scale up rapidly across the institution, both for inpatient visits and outpatient care. We've done things such as change workflows throughout our hospitals and our ambulatory clinics in order to minimize contact between patients. And then importantly, in order to ensure again, that we're providing high quality and safe care, we've been cohorting, COVID positive or persons under investigation patients, making sure that we have separate workflows to care for those patients. We test all admitted patients, all patients before a procedure, any laboring moms, patients who have COVID associated symptoms or patients with known COVID exposure. So our testing capacity at Stanford and our turnaround time has allowed us to identify COVID patients early to ensure the safety again, of all our patients, families, providers, and staff.

I will just mention a few numbers if that's okay, to date nearly 13,000 employees across Stanford Medicine, including Stanford Children's Health have been tested. And amongst those staff and providers tested only 0.3% of asymptomatic people have been positive for COVID-19. The data shows the measures we've been taking to slow. The spread of the virus have been incredibly effective. In addition, we've tested nearly 5,000 patients at Stanford Children's Health. And again, amongst those patients, those children who are asymptomatic at the time of presentation, and we've only had a 0.3% positivity rate versus for patients who are symptomatic it's at about two and a half percent

Host: Dr. Lund, anything to add. When we talk about safety protocols and everything that you all are doing, anything you want to add to this?

Dr. Lund: I think it's really important though, for people to understand that actually the hospital is a safer place by all our testing criteria than the outside world. There've been reports that, you know, the COVID positive rate in the outside world is somewhere around 7% or 10%, depending on where you look, but in the hospital, the rate amongst healthcare workers and even amongst our symptomatic patients has been extremely low. And I think patients can kind of take heart in that.

Host: Yeah. Agreed. I think we're, you know, hearing stories from across the country of people who have not gone to the hospital when they've been experiencing strokes other emerging conditions, or even for fear of COVID-19. And the reality is that there's no safer place than the hospital. That's where the doctors are and the nurses and the medicine and the PPE and the testing and all of that. You were so right. So Dr. Lee, what are pediatricians recommending now to make sure our kids are up to date on vaccines? You know, well visits can be telehealth, of course but vaccines, not so much. So where are we at with that?

Dr. Lee: So Stanford Children's Health has a robust set of primary care practices that are delivering really essential care to the children that we serve. It's really important that we continue to vaccinate children in the context of the pandemic. And particularly as social distancing requirements are relaxed over the coming weeks. You know, our practices are here to serve our children and families. And we really encourage parents to talk to your pediatrician about rescheduling. These important visits, of course, telehealth will continue to be provided for all those visits where those services can be delivered via telehealth, but it really is important for our children to stay up to date on vaccines. We're seeing across the U S that millions of children are going under vaccinated during a time when we want to ensure that we're preventing bone COVID illness, as well as routine childhood illnesses. So anything we can do again to prevent infection in our children is really important and essential for part of the care that we deliver.

Host: So, Dr. Lund, how have you been utilizing telehealth to bridge that gap for parents, you know, that have questions and concerns for their pediatricians? We've touched on it a little bit, but maybe you can speak specifically about those telehealth visits.

Dr. Lund: So one of the things we're working on is actually algorithms or ways to alternate telehealth visits within person visits. So for example, a busy Doctor may see one patient in the office and then do two telehealth visits or some, you know, ratio like that, so that the waiting rooms can stay empty. Patients who come to the clinic can be immediately put into a room again. So they're not exposed to a large number of other people. The telehealth part of the equation has been very interesting because as Dr. Lee mentioned, we've been working on telehealth solutions here at Stanford Children's Health for quite a while, and actually have a very good system in place so that we can provide telehealth to families from their home computers, from their iPads or their tablets or other digital devices. And on the Doctor's side of it, he or she can actually see the child and the parent right from within the medical record so the documentation can be going on at the same time as the visit.

Now, one of the limitations of a telehealth visit is it's hard to do a physical examination to some degree, although there are aspects of the physical examination that can be done over telehealth. And again, one of the interesting things we've discovered is that telehealth actually works extremely good for mental health services. And it also works extremely well for physical therapy because the physical therapist can help a child work through their physical therapy routine while they're watching them on a TV screen or an iPad screen rather than seeing them in person. So again, this is a new application of technology that we're going to get used to. And I think it's here to stay

Host: Dr. Lee for children who have chronic medical conditions. Is there any different protocol for those families that have to come in?

Dr. Lee: So we are here and available to care for all children with chronic medical conditions. You know, our healthcare system is ready to rapidly detect and respond to any increases of COVID-19 cases in the community. We have robust infection control programs in place, including available PPE or personal protective equipment to ensure we can provide safe and reliable healthcare. In addition, of course, as Dr. Lund mentioned, we have telehealth services available to provide care to those children who we can maintain through telehealth visits. However, we do want to highlight that, you know, deferral of care can result in patient harms and that the impact of COVID-19 is clearly beyond that of COVID itself. So it's important to ensure that the children who need to be seen for care are able to come in and know that we are providing a safe place to come for those who need to be here. We continue to provide screening at all the entrances of our hospitals and clinics and masks are required for everyone as you know, consistent with the County mandates. We will continue to have visitor restrictions in place in order to protect our patients, families, providers, and staff, and those policies we anticipate will continue to evolve over time, both as the local epidemiology changes and as our County partners or our public health partners ensure that our visitor policies are in concordance with their guidance and mandates

Dr. Lund: Scott, one other thing I might add is that there are a number of chronic patients, chronic care patients who come back to the hospital on some kind of a regular cadence just to be checked. So it might be to be checked or a tracheostomy tube and make sure that's fitting well, or a gastrostomy, a feeding tube in the stomach, makes sure that's fitting well. And a lot of those checks actually can be done remotely. And we've again, had some examples of situations where telehealth actually saves parents, very significant travel time to come to the hospital for regular routine check that can be done safely by telehealth. But as Dr. Lee mentioned, what we don't want to do is have parents feel that care should be delayed. If they're concerned, and they think their child needs to be seen, it's perfectly safe to bring them to the hospital or the clinic to be seen. And we encourage that.

Host: Absolutely. And you mentioned earlier about the algorithm. So I want to talk about that with Dr. Lee here. So whether it's an algorithm or decision tree and how to handle patients coming through for urgent and emergent conditions. I think the biggest question for parents is probably are they allowed to accompany their children, Dr. Lee?

Dr. Lee: Absolutely. So since the beginning of this COVID experience, we have absolutely had algorithms in place to ensure that we safely manage both symptomatic and asymptomatic patients. And as Dr. Lund mentioned, we continue to have separate workflows for those patients in order to cohort or separate patients who might be symptomatic from those who are asymptomatic and here for other conditions that require, continue an ongoing management for patients coming through for urgent and emergent conditions, you know, we continue to make sure that we are a place that can serve our children and our pregnant moms. We are uniquely equipped to handle all cases at all times, even in these difficult circumstances. And we continue to maintain the highest standards for safety. At this time, all of our visitors are screened for COVID-19 symptoms prior to entering any of our facilities, whether it's the ER, our clinics, or the inpatient setting we've enabled multiple approaches in order to make sure that we continue to provide patient and family centered care, even during this difficult time.

So one nice example is these newer technologies where we have digital tablets that are used for communication with care teams outside of the patient rooms, if they're in isolation and those same tablets are used to communicate with family members and to ensure that people can be present on rounds, even if they can't physically always be there with their child. We also have visitor policies in place where, although there's only one visitor allowed at a time, we are trying to continue to work with our family centered Care group in order to ensure that we again are ensuring the safety and the care of our teams and our patients, while also providing the care that's really needed for children to get better. Or for example, for moms who are delivering to ensure that they have a partner there for them, and that we can continue to deliver that care in a safe and effective manner.

Host: Yeah, that sounds good. Especially, you know, moms to be, have to have somebody there with them, whether it's dad or grandma, whomever, it might be, you just can't imagine going through that by yourself. So there's a lot in the news right now, Dr. Lee about inflammatory syndrome associated with COVID-19 and it's appearing in kids, and it's confusing for us parents because we're just not quite sure what it is and what it means. So can you talk a bit about that and what parents need to know?

Dr. Lee: There's a lot that we're continuing to learn about multi-system inflammatory syndrome in children. What we do know is that it can affect multiple organ systems such as your heart lungs, kidney brain, skin, eyes, GI tract, or blood counts. The early experience from the UK and from New York and from other areas has identified this as a condition associated with persistently high fevers, oftentimes rash, vomiting, diarrhea, abdominal pain, bloodshot eyes. They don't always have respiratory symptoms that are more classic for a COVID-19 infection. However, they do have evidence of prior infection whether it be through PCR testing or serology testing, or a known confirmed exposure to COVID. It's not clear yet why some children are getting sick and others don't, but we are collaborating with our professional societies and public health officials to ensure that we are not only providing the best possible care these patients should they come into Stanford Children's Health. But also that we are providing up to date care and working with public health officials around reporting to ensure that we can continue to learn as a community about how to care for these patients. It's interesting. And a little bit distinct from another syndrome called Kawasaki's disease. What's a little more unusual about MIFC is that for Kawasaki's we tend to see it in younger children, whereas with MIFC, we are now seeing this in older children and teenagers who were previously healthy.

Host: As we begin to wrap up here, Dr. Lund, let's go through this one last time. Let's reiterate and reassure parents that it's safe to get healthcare, whether it's at the primary care offices or the hospital, if your child needs care, they need to come in. Right.

Dr. Lund: That's absolutely correct, Scott, right from the start, we have been focused on safety. We have been focused most importantly, on the safety of our patients and their families, but also on the safety of our staff and our frontline providers. Obviously, if our frontline providers were to get sick, we wouldn't have people to take care of or pair of the patients. So we've really focused heavily on making sure that we have everything we need to keep patients and healthcare workers safe. We want the hospital to be a safe place for people to be. We want them to feel comfortable that it's safe to come to the hospital. And that's one of the reasons why all the testing and all the PPE and all the work we've been doing, and we continue to monitor is so important. It's really very important that parents don't postpone the necessary care that their children need.

As Dr. Lee talked about, vaccinations are really important, even though we're very worried about COVID-19, in the grand scheme of things, believe it or not, measles is a more D dangerous disease and COVID is. And so we have to be sure that children are being vaccinated appropriately. We are beginning to see an increase in complexity of some of the diseases that children get because the care has been delivered. So for example, we seem to be seeing more complex appendicitis than we had been before. COVID, and we're relatively convinced that that's because people are reluctant to bring a child with abdominal pain to the hospital. So we don't want patients to feel that the hospital's not a safe place to come, and we encourage them. If they feel the need is there to be comfortable, that they can bring their child here. And we really want them to know that the hospital and primary care Doctor's offices are very safe places to be

Host: That's all really well said. Thank you so much, Dr. Lund. Dr. Lee, last word to you.

Dr. Lee: We are here to provide care to our patients and we are a safe environment, and we are here to ensure that we are maintaining and improving the and welfare of the children and the families in our communities, and to work with our partners in the community as well, to care for all involved.

Host: Thank you both for being on sounds like you guys are really on top of your game. It's going to be an exciting and interesting period of time as things begin to open back up and more and more people start coming back in and, you know, keep up the great work and everybody stay well. For more information on how Stanford Children's Health is resuming care after the State mandated reduction in services, visit Stanfordchildrens.org, and we hope you found this podcast to be helpful and informative. I'm Scott Webb. Thanks for listening and stay well.