Preparation and Dedication at America's COVID-19 Ground Zero

How EvergreenHealth managed the first known coronavirus outbreak in the U.S.—and what they’re doing now.

EvergreenHealth in Kirkland, Washington, found itself under the global spotlight this past February as they reported the first death from COVID-19 in the United States. Located near the Life Care Center of Kirkland long-term-care facility, EvergreenHealth treated dozens of Life Care patients in the first major coronavirus outbreak before the disease rippled across America and the globe.

Leading the EvergreenHealth response, along with his colleagues, was Dr. Ettore Palazzo, MD, Chief Medical and Quality Officer. His responsibilities have included overseeing clinical quality and safety, infection control, risk management, pharmacy and hospital medicine services, and medical staff services. We spoke with Dr. Palazzo to gain insight into how EvergreenHealth was prepared for the outbreak, the steps it took to keep patients, visitors, and staff safe, and ways in which the health system is determined not to be complacent as COVID-19 continues its course.

When the first two COVID-19 tests EvergreenHealth submitted to the Washington State lab came back positive on February 28, the results might have left other healthcare providers surprised and unprepared. But at the time, EvergreenHealth had been reviewing its relevant policies and procedures for several months. The hospital’s High-Consequence Infectious Disease (HCID) Pathogen Committee, formed six years earlier during the Ebola outbreak, had revived its regular meetings beginning in the fall of 2019.

“Originally, the HCID Committee was formed to assess the policies and do some revisions, adjustments, and an accounting of what we needed in the organization, both from a PPE and a facilities standpoint,” says Dr. Palazzo. “With the threat of Ebola in 2014, we looked at how patients potentially would enter the emergency room, how they would be isolated, what staff would treat them, and what areas of the hospital could be segregated off. The HCID Committee decided to go ahead and bring everyone together again, to start re-looking at those policies and expand beyond just things like Ebola to other respiratory-type pathogens. Just two months later, SARS-CoV-2 was discovered and announced in China in late December.”
Dr. Palazzo

The first two positive coronavirus test results came back to EvergreenHealth late in the evening on Friday, February 28. Immediately, the hospital activated a command structure outlined by the HCID team, which was based on the National Incident Management System devised by FEMA. Areas of the hospital were designated to move fully into negative airflow. But with more positive cases on the horizon, protecting the staff and patients at EvergreenHealth became a concern of state and federal officials.

“It became very clear, as the case counts rapidly increased and it went beyond just EvergreenHealth, that PPE supply could potentially be an issue,” Dr. Palazzo continues. “The CDC were on-site here within the first three days. We also worked with our leaders, both at the state level and in Public Health Seattle King County, our local public health department. We discussed what made sense from a PPE-usage standpoint, with the understanding that we were moving from conventional into contingency phase. At the current burn rate, we could potentially run out of PPE.”

During the early periods of the pandemic, scientists were working hard to determine the nature of SARS-CoV-2 transmission—in particular, whether the mode of transmission was airborne or via droplet mechanisms. Based on recommendations from the Washington Department of Health and WSHA (Washington State Hospital Association) in early March, EvergreenHealth adopted a “Special Contact/ Droplet Precautions” protocol for care of COVID-19 patients, with the use of N95 or higher respirators required when caring for any COVID-19 patient undergoing an aerosol-generating procedure.

Also, in the early days, universal masking was not recommended. That, too, soon changed. “We moved to an optional extended-use masking policy early on, because there was evidence that we could mitigate risk and enhance source control for potential employee-to-employee exposures,” Dr. Palazzo recalls. This then transitioned to a strict universal-masking policy, requiring all employees, patients, and visitors to wear a mask. A team led by Dr. Francis Riedo, Medical Director of Infection Control and Prevention at EvergreenHealth, was instrumental in guiding all the divisions of the hospital in making these adjustments.

“It was a coordinated effort among all the divisions of the hospital to make sure that we were doing everything as safely as possible, both for our patients and our staff,” Dr. Palazzo explains.

“The Infection Control team was the hub of the wheel, working with all the departments to ensure that we were following all the surface-cleaning guidelines that were coming out, and implementing the necessary changes as the situation evolved and additional precautions were required.”

With the COVID-19 pandemic now headed into a second year, Dr. Palazzo and the team at EvergreenHealth have identified four key pillars to keeping staff and patients safe. 

  1. Negative airflow and proper personal protective equipment In dedicated areas of the hospital, creating negative airflow moves air out of the rooms and into the atmosphere, not into the central core. Following the recommendations of the CDC and state health departments to create the right PPE provision and negative-airflow environments also lowers risk for other patients in the area, as well as for employees. 
  2. Source control “Once we had clearly identified how to take care of patients and make sure the staff taking care of those patients were safe, how did we deal with the fact that this was now becoming a community-transmission issue?” asks Dr. Palazzo. “I could be at the grocery store, get exposed, and bring it with me to work or home. So source control became a big piece of that, which included universal masking here in the hospital. It became very, very important to reduce and really drop the risk of a  healthcare worker–to–healthcare worker or employee-to-employee exposure that could happen, totally irrespective of you being in the hospital.”
  3. Symptom screening For all individuals entering the facility (patients, visitors, and staff), it is important to know if they are potential carriers of the virus. Asking patients about their travel history was standard from the onset of the epidemic, but once COVID-19 symptoms became readily identified, active symptom screening, including temperature monitoring and symptom checks for all individuals entering the facility, became standard. “For employees who screen positive, they do not work and COVID-19 testing is performed,” says Dr. Palazzo. “And if you’re a visitor and you screen positive, you’re not allowed to enter the facility, and recommendations are made for you to be seen by your care provider.”
  4. Social distancing While it’s become the norm in American public spaces and buildings, social distancing had to become a necessity in hospital settings as well. “Here in healthcare, we're so used to working shoulder-to-shoulder, getting handoffs about patients when we’re rounding with one another,” says Dr. Palazzo. “But it became clear that we needed to make sure that when we’re having meetings in the hospital, or there are visitors queued up to come into the hospital or elsewhere in a clinic, procedures were implemented to keep our staff and visitors appropriately distanced, even with the masks in place, to minimize risk.”

Dr. Palazzo emphasizes the need to stay vigilant. “In the early days, I think it was really easy to make a case for all the interventions that we’re now familiar with: the handwashing, social distancing, making sure you're wearing your mask,” he says. “Our biggest challenge now, I think, is making sure we don't become complacent. Our organization needs to continue to remain nimble as new recommendations come out, whether that’s a new vaccine that becomes available to us, or how we’re going to administer it to frontline staff and ultimately the community. PPE recommendations may change, based on how the science comes in. We constantly have to be nimble and ready to adjust as the science guides us, and make sure that we’re ready to respond. What we know now will be different from what we know six months from now—just as what we know now is quite a bit different from what we knew in the early days.”

Through it all, Dr. Palazzo remains pleased with the staff’s agility at EvergreenHealth. “Our successes have really been related to our ability to adjust. Our culture enables us to do that. We need to remain that way so we’re not waiting—otherwise, we’ll suffer the consequences of not being able to implement change quickly." 

Ettore Palazzo, MD is EvergreenHealth's Chief Medical and Quality Officer. He is responsible for EvergreenHealth’s clinical quality and safety. Dr. Palazzo also oversees risk management, surgical services, the pharmacy, and medical staff services.