Testing Stockpile Ventilators | The Pediatric Mental Health Crisis | ECRI's Mission Trip to Panama, Floating Doctors

Paul Anderson: Hi, and welcome to ECRI Now, a show about healthcare insights from the experts. I'm your host, Paul Anderson. Today we'll talk about a trip ECRI staff took to work with a medical volunteer group in Panama and explore the number one item on this year's list of the top 10 patient safety concerns. First, we'll talk to Brad Bonnette in the ECRI Lab about stockpile ventilators devices that are kept on hand in case of a surge in patients needing respiratory support. In the early days of the COVID-19 pandemic, you may have heard about ventilators being deployed from the National Strategic Stockpile to supplement devices in short supply in provider organizations. ECRI senior project officer Brad Bennet is testing the types of ventilators that might be used to replenish such a stockpile to see if they'll be useful in the next emergency. Brad, we're here looking at what we're calling stockpile, sometimes we might call them mass casualty ventilators. Yes. What makes these different than what I'll call a traditional ventilator?

Brad Bonnette: Nothing I think is the right answer. Yeah. These are devices that you could walk into a hospital and see being used on patients right now for routine patient care. These are transport ventilators, maybe sub- acute ventilators. They're not fully featured, fully decked out ICU ventilators. They do have the modes and features necessary to take care of patients in ICUs, and it wouldn't be that unusual to see one next to an ICU bed. These devices have plenty of advanced ventilation modes and features. The thing that makes them that we are looking at is how easy is it to put them in a box in a warehouse and not touch them until you need them? What do they do? How do they help you make sure that when you take them out of the box they'll work? These ventilators would've been very useful during Covid, and so if people had them, they would've used them. They would've been in short supply and any that were not being used would've been pulled out and being used. These weren't the ones that were in the stockpile. We maintained a national stockpile and there were ventilators in it when covid happened. You could have more ventilators than you need routinely and cycle through them. And so you're using all of them and you're trained on all of them, and so you just have more than you need so you can deal with a surge. The more likely scenario is you have 50 or 100 in a warehouse somewhere and you'll have to change the batteries every two years. You might have to do some preventive maintenance regularly, but that's the only time they'll be touched probably until they're needed. One of the things we're trying to assess is how do they look like when you take them out of the box? What sort of instructions are there? Do they have the breathing circuits you need with them? Do you have all the accessories you need in the box or with the box ready to go? When you take it out and you turn it on, does it work? Obviously these do, they came from the vendor, but what are they doing to make sure that that'll be true 10 years from now when they've been sitting in a box? That's one of the things we're trying to assess, and that's why we call the category stockpile ventilators. What are the characteristics that we care about for devices that might be in a warehouse until they're needed?

Paul Anderson: Is that something we're seeing healthcare organizations or other entities doing now is trying to build up a stockpile?

Brad Bonnette: It's primarily government agencies that are doing it, and the US maintains a strategic national stockpile, which I'm sure some folks heard about during covid and has for many years. That has ventilators in it. It has PPE in it. There are some states that also have their own stockpiles, potentially even big metro areas, certainly after COVID, that is something that is on people's minds. So it's something that we want to talk to and help people think about in a rigorous way, because one of the things we learned during COVID is you are probably going to, if you need to get devices out of the stockpile, they'll probably need to be pretty sophisticated.

Paul Anderson: If the need is great enough to need that right, then we're not going to need a basic piece of equipment. We're going to need something advanced because the crisis is causing that.

Brad Bonnette: Absolutely. The way people are probably going to be sick is going to be in a way that's going to require advanced ventilation modes, advanced features that do lung recruitment and things like that. It's not very likely you'll have a bunch of patients who just stop breathing, but their lungs are healthy, and that's what basic ventilators are good at. They will make your lungs move if your lungs are healthy, but for some reason you stop breathing. If a patient has some sort of muscular condition and they lose the spontaneous breathing drive, then they don't need a very sophisticated ventilator to just breathe for them the rest of their lives. That's not what we're likely to see in a respiratory pandemic or even a sort of event that might cause a lot of injuries like an earthquake. You'll have a patient that's got some sort of chest trauma and those lungs aren't healthy, that you're going to need something that can apply a lot of pressure because the rib cage has collapsed, and you need to provide a lot of pressure to keep those lungs open to that situation.

Paul Anderson: A lot of what we're doing is sort of anticipating what might the next event look like. What can we learn from COVID to apply to the next situation, even though we don't know what the next situation's going to be?

Brad Bonnette: Be? Yeah, well, this is the way I think about it. When I was earlier in my equity career, I did an evaluation of what we at the time called mass casualty ventilators. That was after bird flu and SARS where they were sort of near misses and we were afraid there might be some global respiratory pandemic and it didn't quite turn into that. People died. It was a real thing, but it didn't get to the global scale. We tried to take those lessons. What kind of ventilators would you need for a real pandemic and what you squirrel away? From all the experts I've spoken to, our best guess is if we have something else like that, it'll be similar to COVID. You're right, you don't want to necessarily fight the last war, but you want to be able to fight the last war, right? It'd be great if you can fight the next war, but if you don't know what that is, you should at least be able to fight the last war. That's the advice we're taking is you should at least be able to take care of, have devices that would be useful if COVID part two happens. If something else happens and you can reasonably guess what it might be, sure prepare for that too. Step one is we're ready for if COVID happens again basically. Looking at the devices that are in the stockpile now, I'm not sure we are ready for that quite yet. There are a lot of devices in there that don't really meet the standard, but there are a lot of great devices that would be useful for that, and we hope to look at them and provide some guidance on that.

Paul Anderson: Good. All right, Brad, thanks so much for your time today. I appreciate it.

Brad Bonnette: Yep. All right.

Paul Anderson: To learn more about the work our device evaluation team is doing, check out our ECRI lab tour webcasts. This year's top 10 patient safety concerns report features the pediatric mental health crisis as its number one item. Teens and even younger children were already reporting high rates of depression, anxiety, and other challenges before the COVID-19 pandemic made things even harder for them and their caregivers. We spoke to Laura Stone, a risk management analyst at ECRI about what made this the lead item in this year's report and some of the steps we recommend providers take. With ECRI's 2023 list of top 10 patient safety concerns now available, we're back to talk to Laura Stone, a risk management analyst at ECRI in more depth about this year's report. Laura, the number one item on the patient safety concerns list this year has to do with pediatric behavioral and mental health. Can you tell us a little bit about what that item's about?

Laura Stone: Thanks, Paul. We are experiencing a pediatric mental health crisis. We've had guidance from the American Academy of Pediatrics as well as the White House and the Office of the Surgeon General. This should really not come as a surprise to anyone. Concern for our youth's mental health was already on the forefront during the previous decade. It's not easy growing up for any generation, but Generation Z and Alpha behind them are really facing a lot of struggles from social media, gun violence, and other socioeconomic factors. Then the Covid- 19 pandemic hit and it hit everybody very hard. You had lockdowns, social isolation, you had financial uncertainty as well as just months of really years now of uncertainty about the virus. That's taken a toll on our youth. The reason that this is so important is because youth, children, adolescents, they don't necessarily have the resilience that adults do. We're definitely not saying that mental health in adults is not important. It is. We are saying that we need to pay attention to this particular population because they don't have that resilience. They don't have those decades of experience to be able to handle some of these challenges.

Paul Anderson: If we're seeing this huge surge in need for pediatric behavioral health services, do we have anything like the workforce we need to provide that need?

Laura Stone: Right now, unfortunately, no. There was a lack of pediatric behavioral health professionals in the 2010s, and I think just the universal staffing shortages that we're seeing is impacting behavioral health. There is a lack of access to care, and that's something that we do talk about in our top 10 report is that not everybody who has been diagnosed with anxiety or depression receives that care. About half of children who are diagnosed as anxious or depressed, actually less than half go on to receive care, about 40% actually get that care. Even that number is a little bit misleading because different populations have even less access to care. Asian youth, there's only 22% that get the treatment that they need. Black youth, it's only about 32%. There are really a lot of health disparities across this population when we're talking about access to care.

Paul Anderson: I almost hesitate to ask, but what are some of the consequences for these kids of not being able to get the care that they need?

Laura Stone: One of the things that we've seen is a rise in how many kids are diagnosed anxious, diagnosed depressed. From 2016 to 2020, which is the last year that we have data for, there was about a 29% increase in children diagnosed with anxiety and a 27% increase in children diagnosed with depression. Now, those are kind of abstract numbers. What that means is 5. 4 million children are diagnosed with anxiety and 2. 7 million are diagnosed with depression. One of the statistics that I looked at, I looked at children from age three to 17, and to think about a three year old with depression is really hard. I think the COVID Pandemic really brought that attention to the forefront and made a lot of people realize that toddlers, preschool, young school- aged children are affected by this. They're affected by these lockdowns, the social isolation. Having so many kids with anxiety or depression can lead to suicidal ideation. We've also seen an increase of children presenting to the ED with suicidal ideation, and that's something that's really concerning and really sad and something that we need to address.

Paul Anderson: When we spoke previously about the top 10 report, we talked about the fact that it's not just a list of things that are going on. We want to get into some recommendations. What can organizations and providers do about it? What are one or two key recommendations that we offer to deal with this? This is a huge systemic problem.

Laura Stone: We approached our top 10 list this year from a total system safety. One of those approaches is leadership, governance, and culture. Your first step is really securing leadership support, because without them, you're just not going to have the resources to address this issue. You really need to assess, like you said, do we have anybody who can help these kids, any behavioral health? Do we need to hire any more people or contract out? What can we do once we identify these kids? Do we have these systems in place? Another recommendation that we have is universal screening. The AAP recommends universal screening for children for anxiety and depression based on age. You want to screen everybody, but you want to make sure that you're doing so age appropriately. SAMSA also has some recommendations for screening for substance use, which is a related but slightly tangential issue, but you still want to make sure that you're identifying these children.

Paul Anderson: You mentioned that's obviously not a really a happy surprise to find. What was the role for you in working with folks around ECRI? We think about the healthcare workers burnout. How about your own burnout in dealing with that item?

Laura Stone: Definitely. It was a challenge to write this a little bit. It was something very close to my heart, something that I do experience personally with my own children. You want to make sure that they grow up not just physically healthy, but mentally healthy as well. As a mother, it did hit me a little bit harder than it would have maybe if I didn't have children. But here at ECRI writing this, we are definitely a very supportive, collaborative environment. I got to pair with some of my other colleagues who are mental health experts, who are pediatric experts, and we had brainstorming sessions where we just talked about this issue and that meeting started out with us really just giving our own feelings on this topic to put it lightly. We talked back and forth and said, this should really be the number one item. This is so important. We didn't know if it was going to become the number one item, but this was something that to us was definitely very near and dear to our hearts.

Paul Anderson: Laura, thanks so much for your time.

Laura Stone: Thank you, Paul.

Paul Anderson: Be sure to check out ecri.org to download a copy of this year's top 10 report, and be sure to check out the ECRI blog for additional updates. In February, a team from ECRI and ISMP spent a week in Panama with a group called the Floating Doctors, whose mission is to reduce the present and future burden of disease in the developing world and to improve healthcare delivery worldwide. We sat down with Julie Thomas, an ECRI patient safety analyst and consultant who was part of that trip. Julie, tell us a little bit about the Floating Doctors. Who are they? Where are they? Why are they floating?

Julie Thomas: Well, why are they floating is a great question to start with. They are floating because floating doctors is in rural Panama, San Cristal Island as part of Bocas Del Toro Islands. They serve the indigenous villagers and people of the islands of Bocas Del Toro. Again, floating doctors is because the only way to get anywhere is by boat. They have a base camp, which is almost like a military base camp like barracks, and that's where all the physicians, the volunteers, the providers stay who work for Floating Doctors, and then they take the boat every day to the various clinics. We were hands on all week long. I'm a registered nurse, Shannon DeVille is a registered nurse. We had Rita Zhu, who is our president of ISMP. She is a pharmacist. Our leader, Marcus, of course, is an anesthesiologist physician by trade. We all put our clinical hats on and we got dirty. We loved it. I was able to do vital signs, triage. I even gave intramuscular antibiotics to a very sick young girl. Marcus was debriding wounds. Shannon was triaging too. Rita ran the pharmacy, was helping them come up with policies and procedures to make things more effective. I was even a dental assistant one day. I helped extract at least 35 teeth one day.

Paul Anderson: Oh my goodness.

Julie Thomas: My surgical background came in handy with the instruments and cleaning and disinfecting and sterilization. So

Paul Anderson: A little bit different than sitting at a desk here at ECRI.

Julie Thomas: Absolutely, absolutely.

Paul Anderson: Julie, you mentioned that this is sort of in an island region of Panama. Maybe if you could frame it a little bit more, is this sort of on the Pacific or the Atlantic side, if you know offhand, and tell me a little bit more about the types of folks that live there, what their conditions are?

Julie Thomas: Within San Christobal, remote villages all throughout the area, and they're very remote. Everything is by boat. Houses are made out of basic wood structure, no running water in some places, latrines, there's literally a hole in the ground for a latrine. Families are living in huts, maybe about 10 or 15 people, some of them. No clean running water, no electricity in certain areas, certainly no internet in certain areas. The climate is tropical. It was 95 degrees every day. When we talk about the environment, clean water, we had to bring in our own water from the base camp that we could use for hand washing and for drinking and for giving medications. The environment, the humidity, one of the biggest challenges that they have in that environment is parasites. They've got a lot of dogs and cats, and these cats and dogs are living with the families and the dogs are in the wild eating whatever, and they get worms as a parasite. Now the families are getting worms from the animals and it's just a continuous cycle. Really it's really tough for them to get that under control because it's such a cyclical thing. The environment is probably one of their biggest challenges.

Paul Anderson: How are those similar or different from what we see here in the US?

Julie Thomas: Well, I think a lot of times we don't realize how many rural areas there truly are in the United States. We have Alaska, we've got what do they call them? Healthcare deserts. We have so many rural areas in the United States that people don't realize, and I think we can parallel that to Panama because sometimes getting to a hospitals over an hour, it's either by boat, by an airplane, the access to those hospitals and other levels of care. I think we take that for granted in some of our metropolitan areas around here. I know myself, I'm consulting on a clinic in Alaska. They need to take an airplane to get to the closest hospital. If you have a critical patient, there's a lot of care coordination involved with that. In staffing, the volunteering, I believe their volunteers are there for about four to six weeks, and then they turn over. They have new staff coming in every few weeks. I like to parallel that to the pandemic. With the staffing crisis we have now is because there's a level of consistency that we need to meet in healthcare and it really emphasizes the need for standard operating procedures and policies and really educating staff and making sure we have those competencies to provide consistent care.

Paul Anderson: What is something that really stuck with you? You were there for a week. You described already being involved in dental procedures and administering meds and doing all sorts of things. What's an image or two images that are really going to stick with you?

Julie Thomas: When I reflect on my trip to Panama and my experience, the biggest thing that I take away from is that we live in so much excess in the United States. They're minimalists, they make do with what they have. They're resourceful. I think I've changed the way I go grocery shopping. I've changed the way I clean my house, the way I look at my cart on Amazon. I don't need any of this stuff. It really has changed my perspective in life is to realize what we need and we don't need in life and what we appreciate. There's a big sense of community in Panama, and it really resonates when I came back to the United States to see the materialism and the competitiveness. Don't get me wrong, competition is great because that makes people better. At the same time, I think we need to just appreciate our community more and what we have and not take anything for granted.

Paul Anderson: Julie, thanks so much for spending some time with us today.

Julie Thomas: You're very welcome. Thank you.

Paul Anderson: Be sure to visit ECRI on Instagram to see more pictures from the trip, and go to floatingdoctors. com to see how you can support their mission. Thanks for watching ECRI Now. To find future episodes, visit us at ecri. org. Until next time, I've been your host, Paul Anderson.