Problems with communication, testing spurred virus outbreak
Cluster pushed hospital to change for potential second wave of COVID-19
The cluster of cases, which began in late March among 15 employees and was announced in early April, mostly centered around two units at the hospital that had cared for the very first COVID-19 patients. As cases mounted, the outbreak spurred criticism from health care workers who were frustrated over hospital policies and called for the removal of its leadership.
Now, with just one COVID-19 patient at Maui Memorial and the cluster officially considered “closed” by the state Department of Health, hospital officials sat down with The Maui News on Thursday to talk about how the outbreak began and spread, the hard lessons they learned and what they plan to do differently should a second wave of coronavirus cases appears on Maui. Perhaps chief among the takeaways was the need to communicate better — with workers and the community.
“We fumbled the communication. That was a major problem,” said Dr. Michael Shea, ICU medical director and physician lead for the hospital’s Emergency Operations Center. “Not communicating with the community and also more importantly, not communicating with our staff effectively. And I think we fixed that. I think that was a really important lesson.”
The first patients
On Maui, the cases were a trickle at first — visitors who’d come from areas of high risk, residents who’d returned home from the Mainland. Many were travel related, and most communities limited their testing to those who met the criteria of having traveled to China and showed symptoms like coughing and fever.
Kelly Catiel, director of infection control, said that the hospital’s first COVID-19 patient exposure was March 28. A person that she described as “Patient A” was admitted to the hospital with a
diagnosis unrelated to COVID. The following day, the charge nurse learned that the patient had been exposed to the virus by a caregiver in the community. The patient was placed in isolation and tested for COVID-19; two days later, the swab came back positive.
Hospital officials then began contact tracing. Anyone who was identified as possibly in contact or exposed to the patient was put on paid furlough until they could be cleared for the virus. Two health care workers in the telemetry unit who’d been exposed to the patient ended up testing positive.
Around the same time, a person known as “Patient B” was admitted to the hospital with pneumonia “and a high suspicion of COVID-19,” Catiel said. Patient B was immediately placed in an isolation unit and given a test on March 21, which came out negative two days later. Catiel explained that because the guidelines at the time didn’t require “serial or sequential testing,” the patient was taken out of isolation and moved to another unit, where the person stayed until discharge.
But a week later, Patient B still showed the same symptoms. The person was brought back and reswabbed on April 3. Two days later, the result came out positive, prompting more contact tracing.
“Ultimately, we were able to identify the outpatient area where another health care worker was found, which led to the furlough of the entire remaining staff who were there,” Catiel said.
The unit was closed and cleaned, and temporary staff were brought in to fill in for the furloughed workers.
“During tracing, we were able to identify another positive health care worker on the unit where Patient B was previously discharged from,” Catiel said. “This included the health care worker who was identified in the media for working ill when in fact the health care worker likely acquired COVID while providing care to Patient B when the patient had tested negative.”
From there, “the exposure continued to cascade within the hospital because staff members were being floated to different units” due to the low amount of patients in their own units that had been closed during the pandemic, like the surgical unit, Catiel explained.
On April 8, a second unit within the hospital was identified as part of the COVID-19 cluster. Both the telemetry and chronic care units that had been exposed were closed to all patient and staff movement, and everyone was tested for the virus even if they were asymptomatic, Catiel said. The mass testing revealed two positive workers from the telemetry unit where Patient A had been and 14 positive patients and 32 health care workers from the chronic care unit where Patient B had been.
Catiel explained that the risk of spreading the virus was greater in the chronic care unit where patients are unable to do daily activities on their own and need the help of nurses. Because of the heavier workload, the manager rotated staff on a daily basis, which helped prevent burnout but also meant that multiple staff could come in contact with the same patient during their stay.
Contact tracing, notifying staff
Contact tracing was a struggle. When COVID-19 first began, the process had to be done manually, with Catiel and other infection control staff pinpointing the date the symptoms began and looking three days prior to find any staff or units the patient had visited, including “ancillary staff.”
“So did the patient go to have an X-ray done? Did the patient have a procedure off the unit? Was the patient transported by a hospital transporter somewhere?” Catiel said. “So it did take a lot of time. It took days in some instances.”
Once the hospital set up an Emergency Operations Center on April 15, brought in a team to help with contact tracing and switched to an electronic program that helps pull data from the hospital’s medical record system, the process went much faster, but Catiel acknowledged that the time it took to notify people in the early days was a factor in the spread of the cluster.
Catiel said the hospital followed “a waterfall process,” notifying managers who would then let their units know. But some employees, who said they only learned of the cluster through the media and not hospital leadership, have questioned why administration wouldn’t use a hospital-wide broadcast system to notify them of positive cases.
Shea said because of privacy laws, hospital officials were limited in what they could share.
“HIPAA has always said we’re not allowed to disclose personal information, so if a patient or a health care worker is now sick, we’re not allowed to say to the entire staff, ‘Hey, John Smith has COVID,’ ” Shea said.
“You couldn’t hint at who that person was, and so it became very difficult to be able to spread that out broadly without violating the law. So I think the federal government realized that and has made some changes to those laws to allow better notification of potential contacts.”
Long turnaround times for tests and a lack of communication between the different sectors that were testing — commercial labs, primary care physicians, community drive-thru testing — also created delays in notifying people that they were positive or had been in contact with someone who was.
Shea said that channel of communication between these sectors is improving. The Department of Health and the hospital have learned to be “in lockstep, talking frequently about what testing is being done, making sure the results are shared, both sides, same time, so that everyone is taking the same action.”
“The more rapid turnaround time on the tests has really helped a lot, as well as the increasing in testing capacity in the state,” Shea said. “The tests are actually getting done in state now and in some cases on site.”
The cluster grows
As the outbreak grew, the hospital created “warm units,” areas where patients who were suspected of having the virus or who tested positive for it could be isolated. Each warm unit was walled off with plastic with a zippered door and an antechamber where staff could don protective equipment.
At the peak of the outbreak, there were five warm units, four of which could handle up to 24 patients each, Shea said. The hospital is now down to one 13-bed warm unit in the Wailuku Tower, which is an ICU ward that can take care of a wide range of patients.
Dr. Vijak Ayasanonda, co-medical director of the Emergency Department, said the hospital was prepared to set up a 10-bed warm unit in the ER but never had to.
Maui Memorial stopped visitation, closed all but one entrance for employees and began screening at the door for temperatures and symptoms. They also stopped “floating” staff through the hospital.
Catiel said mass testing of the two units was part of the reason “why that number grew so significantly in such a short amount of time,” swelling from about 15 employees and eight patients when the cluster was announced April 8 to 26 staff, 14 patients and one undetermined case on April 17.
People who got the virus included a Maui Medical Group provider who worked at Maui Memorial, three Hale Makua seniors who were discharged from the hospital and a Lanai resident who came to the hospital for treatment unrelated to COVID-19.
And, most tragically of all, five patients died at the hospital — one case was related to travel, another was community acquired and three were connected with the cluster and were in the chronic care unit, Catiel said. Both officials and the Department of Health said they are continuing to investigate the cause of the deaths, as the patients had COVID-19 as well as underlying medical conditions.
Hospital officials said they haven’t recently been testing patients post-mortem to see if their deaths were related to COVID-19. When asked how they knew that the death toll wasn’t higher due to the lack of testing post-mortem, Shea said that the hospital has been doing systematic testing and that the long-term care unit has been tested at least three separate times.
“Any patients who could’ve been exposed in the cluster have been tested,” he said. “The emergency room still has a very high suspicion and tests pretty aggressively patients who are coming through the ER. So I’m confident that we would have caught any other cases that could’ve been related to this cluster.”
In the wake of the initial negative test for Patient B that led to the widespread exposure of other patients and staff, Shea said that there is now a process in place where a patient who is suspected will in many cases get a second test, and if both are negative, they can move out of isolation. Patients who are leaving the hospital for long-term care or home health services need two screening tests 24 hours apart to show they don’t have COVID-19 “before they go into those high-risk populations,” Shea said.
Dispute over masks
Many have also questioned whether the administration’s policies on wearing masks contributed to the cluster, long a point of contention for staff who said they had been discouraged from bringing their own masks or from wearing them in general when treating non-COVID patients.
After a Kaiser official indicated that masks could help stop the spread of the virus and allowed staff to wear masks in non-clinical settings, Maui Memorial staff had hoped they would be able to do the same. But, the Kaiser-affiliated Maui Health said it would not be changing its policy in light of conserving supplies. On March 31, Maui Health CEO Mike Rembis reversed course, but by that time, some employees had already treated the first COVID-19 patient.
During a news conference after the announcement of the cluster, DOH Director Bruce Anderson said that the hospital’s issues with equipment protocols “might’ve contributed to the outbreak.”
Shea said he didn’t think the mask policy contributed to the cluster, as he thought the delay in getting testing results “was a much bigger factor.”
“At the time with the information that we had, there wasn’t science to suggest that was the right thing to do, and we were concerned that if we started masking early, we could run out when we really needed them,” Shea said.
However, many infection control practices have changed since the pandemic began. Prior to COVID-19, “the idea of someone wearing the same cloth mask made at home from patient to patient would’ve been an infection control nightmare,” Shea said. He and his colleagues acknowledged that “if we could go back, knowing what we know now, we would change what we did.”
Ayasanonda also agreed that “looking back at it, of course, we would’ve said something is better than nothing.”
“There was a lot of reasons why it didn’t happen, and it’s unfortunate. It really is,” he said. “It would’ve been better off if someone had something better than nothing. None of us are disputing that part.”
The long road back
As of Friday, the Health Department put the total number of cases related to the hospital at 57 — 36 staff and 21 patients, though the hospital continues to believe the number will be reduced once investigations are complete.
“No additional testing is being conducted related to this cluster,” DOH spokeswoman Janice Okubo said Friday. “Because investigation findings are preliminary at this time, it is possible final cluster counts may change as additional information is gathered.”
The outbreak forced many changes that officials said they will keep in place in preparation for a second wave. Rembis said that one of the lessons administration learned was that “we need to communicate more.”
“Communicating everything we can with our employees to make them feel more secure is absolutely important,” Rembis said. “And to move quicker and take actions quicker and not necessarily follow the CDC guidelines and the Joint Commission guidelines, but if intuitively we feel we need to do more, try to do things quicker and faster.”
Rembis said the hospital is also ordering as much protective equipment and supplies as possible and is working with medical staff to create a surge plan “so that we are far, far more prepared than anybody could’ve been the first time around.”
Ayasanonda added that the hospital’s surveillance “is much better right now.”
“So although we might be cooling down, if you want to call it that, that we would be prepared,” he said. “We’re not taking down the plastic. We’re not taking down the tent. We might not be utilizing it as much, but we’re not taking it down because we do anticipate the return of COVID.”
Shea said that the hospital will continue to have the Emergency Operations Center and the contact tracing team, and that Employee Health and the Emergency Department will continue to work together on not only data collection but making sure workers could be taken care of in-house.
He and his colleagues said they know it will take time to restore faith in the hospital.
“Trust is earned . . . and it takes one person at a time and one good experience at a time and one story at a time,” Ayasanonda said. “It will be brought back in by those who we take care of.”
Shea said that those who work at the hospital want it to be safe for their friends and family.
“Please believe that everything I do is to make this place as safe as possible for the people here who need it,” Shea said. “The nurses, the respiratory therapists, everybody who works here has loved ones who live on this island, and we don’t want to have to fly somewhere else to get medical care. We want our medical care here, and that has been the mission of everybody sitting in this room from Day 1.”
“We’re saddened that we had a cluster here, and I think we’ve learned all the lessons that we could from that.”
* Colleen Uechi can be reached at firstname.lastname@example.org.