the last saturday in september every year. mark your calendars every year. >> welcome, everyone. press mute if you come on to the phone. the first item on the agenda -- i don't want to be muted because the people need to speak. for those of you who are just joining you, this is the march

17th, 2020 commission meeting and we're doing this for the first time using microsoft. please excuse us if we have any technology issues. this process may be different than we normally do. if i may, i may move on to item 2, the approval of the march 3rd, 2020 minutes. >> do we need to do a call to order and role call? >> yes, thank you. so i'll start with you, commissioner. (role call).

>> we'll move on to item 2, the approval of the march 2 minutes. reviewing the minutes of the previous meeting, does anybody have a motion to approve? >> so moved. >> second. >> all those i in favor? >> do we need to do a role call? (role call).

>> thank you. item 3, the director's report. >> the director's report is in front of you and i would ask that if you have any questions, of course, i'm happy to answer them, but given that the majority of our meeting with focus on covid-19, i will not need what's in front of you, but i'm happy to answer any questions you see fit to raise at the time. >> any commissioner questions? i'm not receivining a public comment request. >> commissioners, if not, we can move on to the next item.

>> item 4, the coronavirus update. >> so good afternoon, commissioners. i'm the director of health. >> hold on. >> everyone, please mute at this point, mute your microphones. >> i talked to dr. kovax and this is not coming over very clearly. >> ok, give us a second, please. >> and there's a delay. >> i think it's just the microphone distance. other things are clear. >> can you hear me commissioners? is that better? >> yes, thank you. >> thank you. >> so good afternoon, i'm the director of health and i want to say how much i appreciate the social distancing intervention

we're approaching today and not to make light of the historic moment we're in our country right now, including here in san francisco. two weeks seemed so long ago for when we were preparing to do our best to manage this epidemic and i will talk about the nine health officer orders that have been issued in the last ten days. and i also will ask dr. irwin from the san francisco general hospital, the lead on our plans going forward. i want to provide you with a little bit of perspective of where we are now. we are clearly in a state where we are looking at community spread and the gph team is

working day and night to do everything we can to bend the curve. when i say the curve, i'm talking about the number of new infections. the goal is to help us prepare as much as possible for eight more cases, and inevitably people dying from this disease. based on the data that's emerging from china and italy, we know that about 80% of people do well.

i will say the patterns are what evacuewe've seen in china with d to how this disease has spread. dr. erogon issued what is radical and it had to be. the shelter in place -- this

decreases the spread of the virus and we think it's important to emphasize this was done for the first time, to my knowledge, as a joint public health ordinance. it's across six counties, as well as the city of berkley. this is pivotal, because we know for the broader social interventions to work, it really needs to be original and preferably state-wide and nation-wide. as we've seen the virus

increasing its spread in various communities and countries, the direction has only been further escalation of efforts. i'm not aware of any jurisdiction that has decreased or frozen the efforts going forward. so going forward with these orders, we believe that we will be continual needing to be aggressive for not a period of weeks but months. right now our focus is on three key priority areas. number one, the social distancing as i talk to you about mitigation of the virus spread and number two is focusing on vulnerable populations, including those over the ages of 60, those with chronic disease conditions including cardiovascular disease, diabetes and renarl

disease. the third is protecting the healthcare worker staff. this is a key thing we're working on across the entire system and having ongoing conversations with human leadership about how to ensure we use the best evidence available to provide the best protection possible against our workforce. the number of challenges as we go forward, i am happy to talk about those challenges. i will also emphasize that given the patterns of the disease, given our region and given our state and country, this is not an issue that the health department or san francisco can solve alone and right now we're doing everything we can in our power to optimize what we have here today. i will also add that with some leadership of our mayor, our

other city departments have come to our aid to decrease the morbidity and mortality of this disease. so i will turn this over to dr dr. thomas to briefly summarize the health order. first, iand then to dr. irwin tk about the surge plan, but before that, i'm happy to answer any questions before dr. erogon goes forward. thank you. >> commissioners? >> commissioner, any questions? >> no. >> i think i want to hear the whole presentation before we ask questions. >> so i'm going move and

dr. erogon will come in front of the camera and we'll switch back again. does that make sense? >> yes. >> thank you, director. i'm going to be brief because there's way too many orders. we realized as we were doing these orders, we were learning on the spot. one of the things i learned most recently are two words which is hours matter. this is how fast we're having to make decisions, in a matter of hours. and so, what we have had to do

is not just see what's happening in other parts of the world but what's happening here regionally with the other counties. i would say this last order to shelter in place happened really quickly. i just want to draw a bigger picture and show you how this fits in. so hours matter. we make decisions and then when there's a little bit of time, you do a little bit of reading and i had the opportunity to read an article that influenced the federal response that was just published yesterday, to give you an idea of how fast it was moving. i do want to share that with you because i think it will help you understand our strategy and our strategy is more aggressive than community mitigation. sthere's isolation toronto and e

of contact. you've been hearing about mitigation which is flattening the curve, dealing with workplaces social gatherings. (pause). (. >> this is called social distancing. the idea behind flattening the curve is that in general we'll get a -- a good proportion of the population will get infected and from the recent data up to

80% will become infected. that's why this is so infectious is because there's pretty much 100% susceptiblity in the population. so the idea of flattening the curve is at the end of the day, you have a lot of morbidity and mortality and you're spreading it out so it doesn't overwhelm our healthcare system. the last strategy, which i just learned today from one of the premiere modelers in our country helping the cdc to guide the strategies. his name is neil ferguson. it's suppression and it turns out we're implementing suppression and implementing the most aggressive approach. and that's where we're trying to get the reproductive number less than one and the way --

(pause). the way that we're doing is that by sheltering in place. the idea is that a lot of people have not been infected yet. by having people sheltered in place, they're reducing their opportunity to be exposed and by not getting exposed, they cannot get infected. but they have to go out to do essential activities like get their medicines, essential workers and then, i forgot the last category.

make sure you get your medicines, food, that was the other category. people have to eat. so you still have some risks and then among -- even though you're asking people to stay unexpose bid staying at hole, you'll have cases that need to be isolated d where our movement has been in the united states. santa clara was convincing in

saying, you are one week behind us and you don't want to be in our shoes. if you're going to do it, do it now. the challenge with any of these approaches, they have to be done over a series of months and so concept use usedually, you woulo pull back and to pull back, youe have to strengthen the public health infrastructure. we need a bigger workforce to shore our tracing and quarantine. if we pull back the suppression measures, we need to dial up the public health activity. otherwise, we won't be able contain. the last thing i want to say to

give you a picture of how quickly this infection explodes. imagine the hospitalization icu cases and deaths that you're seeing is just the tip of the iceberg. this iceberg, you're only seeing the tip and that iceberg doubles every six days. that iceberg doubles every six days and that's why you have this explosion. if nno one can see it coming and that's why we have to be aggressive and be ahead of the curve. there's other orders in there that we're tosse focused on lonm care facilities, sros, hospital visitation. we will be asking providers to cancel essential services and to delay elective surgeries and i think i covered most of them. and there will be more coming as we look at this more broadly and

try to fine tune what we do and there will be more coming and it's been great in getting the support. we've been providing a lot of leadership and inspiration. i want to turn it over to dr. susan erlich. >> good afternoon, commissioners.

i just want to say that i know we're in an incredibly unusual time, very unpresprecedented iny professional carr career and i l grateful to be a part of the department because we're pulling together to do the right thing. i feel good about taking care of people we know to be ill. so moving on to hospitals, over

the past month, i and dr. luke john day have been meeting and dr. kolfax, we've been meeting regularly with the san francisco hospital council ceos and also with their medical nursing and operational leaders. there aren't other regional hospitals who are planning in this way and our efforts have

been the supply and effect of the utilization of our critical care beds. lately through these meetings is that every single hospital has really dramatically changed operations in order to plan ahead and meet the demand that we know will be coming. it's what we call puis, persons who have been tested and waiting for results. so, for example, that includes can celling all elective or nonelective surgeries, as well as nonurgent patient visits. and then what we're trying to do is redeploy the resources that were used in those services into

more covid-related services. and so an example of that is in my clinic, the primary care, each of us in spreading our schedules to identify people -- to be seeking telephone visits. that creates other kinds of duties. so right now, we're setting up a tracking system among all the hospitals and a joint surge plan to help us identify on a daily basis where all of the hospitals are with respect to capacity utilization. the system that we're setting up

is modeled after our surge plan which categorizes our state into green, yellow, orange, red and maroon categories, based on what percentage of our beds and our services are being used for puis relative to our total capacity. since we don't yet have the data for all of the hospitals, i can't tell you what that level is today. i have a pretty good idea, based on the discussions that we've been having and what our own level is. today, there's a yellow level and we entered the yellow category from the green category yesterday. what that means, we have more than nine positive, covid positive patients or puis in the hospital. ucfs more or less is at the same

level we are. they're in the yellow range and then the other hospitals are between green and yellow. so the good news about that today is that we all have plans for capacity, but we aren't yet filling it. so that's the question we are at now. tthe other thing i can tell you that's exciting, we're looking to see beyond the capacity, in our individual hospitals, what capacity we utilize in hospitals that have vacant beds that aren't staffed. and we've identified a unit, a full med surge unit and an old critical care unit at st. francis to use for that purpose. the capacity of the med surge unit is about 40 and the critical care unit is eight. and so we looked at that unit last night and now we're in the

process of seeing what it would cost to staff it. in general, we're looking at a model whereby the basic support services are covered by st. francis and we're looking at registries, essentially, to fill the nursing positions and then a shared model of provider services between dignity ucsf and ucsfg. i'm happy to answer any other questions. there's a lot of detail i haven't covered by i'm happy to answer questions. >> commissioners, how would you like to handle questions? would you like to do it person by person or topic by topic? this is a new way of doing the meeting. >> let's do person by person. dr. chow, you had some questions and would you like to start? >> thank you. i'm really appreciative of all of the work that's been done.

we've gone through our own crises over the years, from the age to the earthquakes. and this is obviously the largest response that affects every single person here we have and i think the person here has handled this extremely well. literally, i'm pleased that we've had such strong representatives.

i think this is wonderful. i have been hearing from the private practitioners that sometimes they are concerned that they may not actually have the resources needed in order to continue to work within their offices such as gowns or simple things like that, or swabs now that we've been able to use commercial lab. i know the medical society has been working with all of you about it and i just wanted to know, what are the challenges and resources and are there other things we can do?

we can't do it alone and i know the department is trying to respond to it and just was interested. that's a large segment of the potential medical providers that, if they don't have the resources, that we don't really have them able to take care of this. these populations. >> i would like to turn it over to dr. kolfax to address that. the basic answer is none of us have everything we need but i'll let dr. kolfax speak to that. >> commissioners, it might ask people in seat to ask all of the questions we have so we're not playing musical chairs. how about we ask dr. erlich call of the questions we have in her

topic area, with your permission. >> that's a good point. dr. chow, do you have anything specific to dr. erlich or do others have questions? >> commissioner guermo. >> thank you, and i want to add my thanks and acknowledgement to dr. chow in terms of how the department is handling this. >> commissioner, hold on. >> appreciate the example. dr. erlich, i'm not sure if this is a question for you or for the team, but with regard to the coordination, through the hospital council, are you also able to coordinate the beds that

supplies the workforce? >> you just went mute. >> who will make that decision for the supply beds and workforces to happen? >> right. so generally, what we're doing is that each hospital is doing the maximum it can to try to create capacity within its own walls. so, for example, canceling elective surgeries creates a capacity that we can use for covid-positive patients. and so we're all informing one another and talking about the measures that we're taking, which are pretty similar.

with respect to that centralized resource at st. francis, i think the idea is this three-pronged approached that i described, whereby st. francis is looking at what it's going to cost to provide the basic supplies and the basic support services like environmental services and food. and we're looking jointly at registry resources that we're trying to see if it can be made available to provide the nursing and clinical staff, non-provider staff and then we're looking at a shared service's model for the providers. the purpose of the joint surge plan is to identify the point at which we would start to trigger those things. so today, what i can tell you is that we have a plan, we're oing on seeing if we can get the resources available, putting aside the question of who's going to pay for them and

figuring out how we can jointly put providers in there for about 48 patients. this is really a day-by-day thing. so it's really the surge plan that will tell us when we're ready to occupy. the last part of -- we keep hearing the audio go in and out, so i didn't catch the last couple of sentences. >> i think what we're working on is the joint surge plan that would give us the indication of when it would be time to pull the trigger, to open the centralized resource. >> and who would pull that trigger? would it have to be an agreement amongst everybody or is there somebody that says, no, i'll pull that trigger. >> you know, we're really working that out. but the way we've been operating

is it will be all of us together. and i think we all, together, assume that eventually there will be some reimbursement made available that helps us because none of us can do it on our own. >> thank you. >> sure. >> dr. chow. >> yes, i did have some questions and i really find that that's innovative and forward-thinking. i also saw that we're preparing in certain areas for more like a mass cash thing. how does that all work out and are there other facilities being looked at as possible joint surge? because you're only talking about 40 or 50 beds. >> right. so the big question in all of our minds and the other thing we're working on right now is

modeling with the best data we have available, noting that nobody can do this perfectly. how many beds are we likely to need? over what period of time? and so all of the efforts that dr. erogon was describing about flatten the suffer i curve is go make it more likely that wit resources we have available to us, we'll be able to accommodate the people who need either med surge or ic beds. the more we can do to flatten that curve, the better able we're going to be to meet the demand with the resources we have. and so we are working with our colleagues at ucsf. they have an infectious disease strike team. we've asked them to model this question for us. how many beds will we need, of what type, what period of time? and so hopefully, i'll have an answer to that question or the

best we can do in the next day or so. and so, if we need something more than that bee, i think we'l need to be looking at the state and federal government to provide more resources and i do know generally that the state is exploring this, but san francisco, if things get really bad, which we don't really know right now, we won't be able to solve it on our own. >> i would agree and i do think that dr. erogon's point of the models that seem to be occurring in different cities might give you, also -- i'm sure you're looking at that -- the idea of how many acute beds you need versus a less acute model. and the centre triage that you have been describing, which i think is great. how does that work? is that when one of the emergency areas become

overwhelmed that they call a central number or you're having meetings? i mean, obviously not in 24-hour communication each day. so just in terms of understanding how quickly it reacts if all of a sudden three cases show up over at cmtv. does that trigger something? >> so hospitals are managing their incoming demand pretty much on their own right now. so we've all tried to create capacity so that not only can our emergency department manage the incoming flow of patients, but we're also creating other resources that allow us to offload our emergency department. so, for example, at the sfg right now, we've expanded the hours of the urgent care clinic in order to be able to do more evaluation of patients on other

sites. we've established a two-tiered triage to cohort patients coming in with suspicious requirement symptoms. starting tomorrow, we're likely going to have another testing site on campus over in building 80 that will further allow us to spread the demand for people coming in to be evaluated. so at this point, hospitals are managing the incoming on their own and the planning we're doing is related to the hospital beds and the icu beds. and we've been meeting, really, twice a week to talk about this. so it's an unprecedented level of collaboration and frequency of collaboration between the hospitals. that being said, we are really making this up as we go along. so that this question of a trigger and when it goes, we're doing our best to create these rulerules as we go along.

>> thank you. that was an excellent answer in terms showing the thinking and the dedication you're all givi giving. >> commissioner, were you raising your hand? >> i think commissioner green. >> oh, commissioner green? >> yes. i've also raised my hand. >> i see you know, commissioner chung. would you like to ask your question? >> i have a couple of questions. thank you for sharing the information and some of the materials that have been ready, it's really unsettling for me. for instance, the number of dates that somebody can be transmitting the virus and how long it takes to shed the virus

and when we think about that and think of the capacity that you just mentioned, i think that is where i'm kind of wondering, what does that mean for us to keep those patients, for how long will we keep them? knowing how long it takes them to shed the virus and what kind of burden would that put on our existing staff? and the other part to this, because this is unchartered territory, i would imagine somebody who might have insurance would show up at csfgh and what do we do when they do that? do we take them on because this is the public health emergency? or do we actually redirect them to their own hospitals.

>> thosa lot of what happens tht people come in, we evaluate them and decide do they have requiremenrespiratory symptoms e start asking questions that evaluate whether they're high

risk for being infected with covid-19? even if we think they're high risk for covid-19, we don't hospitalize all of those people. a lot will send home with instructions to quarantine for 14 days and monitor their symptoms carefully. so we're trying to reduce the impact on the hospital as much as we can. the other thing i want to make sure, if i haven't already, is that the volume that we're seeing in the emergency department is no different than it typically is.

any hospital that runs an emergency department by federal law has to evaluate the person with a medical screening exam and make sure they're stable before they go, irrespective of their health insurance coverage. >> it seems like everything is defying common sense when we look at the mass hysteria and giigin begin to wonder how bad we're impacting the general public

when they think they're symptomatic and how they will respond to this. the other part to this, because it felt like there were gatherings that just happened in florida. so they know where to go. >> dr. kolfax just asked toss focus on questions dr. erlich has asked, in hospitals or what she talked about. i am trying to utilize her time because she has to go back to the hospital. so if anyone has questions specific to her.

dr. green? >> thank you. first of all, you all look slightly haggerred. so thank you for all of the incredible work you've done and the dedication. evacuee talked about howe want d healthy. great gratitude. i know you've been there all weekend and beyond that. all of the doctors feel like this is the internship you did 20 years ago before they loosened the hours. so i'm working in a hospital, as you know, and one of the concerns i have and i would like more information about, the extent to which, really, things can be directed by our dph as opposed to collaborative. we had an interesting call from

st. francis people had with china. there were experts from wuhan, beijing and it was most instructive. what came through, there was a hospital council that had leadership and directed the others what to do and they worried about staffing. i'm wondering how you're thinking that through because obviously testing is difficult to come by and we read about the hospital in connecticut that had 200 nursing hours and some incredible number with one exposure. so i'm wondering how you as a group are thinking about how we're going to manage staffing?

my personal experience is a lot of people call in sick for things that wouldn't necessarily be a sickness and now we're encouraging them to and i can see some decimated by nurses being out on quarantine. then if you could elaborate more about ppe, which i know you can't say much about or you may not know much about. but i know we certainly have inadequate ppe at our place. the real infrastructure of how things get to that surge, and who will take charge would be helpful to understand. >> we'll first let me say that today and so far, at the sfg, we have not had issues with staffing, thank goodness. we're keeping very close track of that and so every department reports in everyday about how many people are out and for what reason. and so we're doing pretty well with that. i think we're helped a lot by

the fact that our department of public health workers are disaster service's workers. we have tried hard to community katcommunicate that we need theo show up in spite of the shelter in place order and in spite of any other order, we need them to show up, if they can. we want them to take care of their families. we want them to take care of their health. it's been working and it's been working with our provider care community so far. that being said, we community that people will get sick. we know that will happen or that they will be out for other reasons. and we're working really hard to try to a, hire nurses and other staff more quickly and the mayor, there's another order today that, basically, waived all of the the charter positions, waived the civil

service positions to make it easier to hire and that's a big relief. we've electriwe've been workingg nurses much faster than we typically do. we've hired nurses. we've reached out to our registries and utilizing those resources and we're doing everything we can that's under our control to try to keep our staffing up to what it needs to be. did i answer all of your questions, dr. green? >> i'm wondering what you foresee as infrastructure and leadership when and if this becomes an italy or wuhan and how you see, based on the interactions to date, how you see the hospitals working together? >> well, as i mentioned, i think the hospitals have been working together really well. within csfg, we have an incredible leadership team.

people have been working around the clock to make sure that we're as prepared as we can possibly be. and that leadership team, thankfully, has redundancy, as well, and i think that's working well. where we have all of the ppe we need, will well have all of the supplies we need? it's tough to come by and we're keeping it under lock and key to make sure that we have it available for the people who really need it. it's definitely not in abundant supply, but we have what we need so far. these are much bigger questions, the questions about testing kits and reagents and ppe, these are national issues. but we're doing what we can to make sure that we have what we need. >> i'm sorry to interrupt. i've just been notified that dre board in ten minutes. and i'm wonder physician w wonde

questions to him. >> that's great. i did have a few questions for dr. erogon and this is dan. first of all, thank you so much for your leadership to you and to dr. kolfa examinatiox and dr. i understand we have 43 cases in san francisco and how many are hospitalized and how many are in icu? >> i will tell you in one second. >> thank you. we understand with the lack of testing kits what we're doing is surveying what already exists out there to get a sense of what our current situation is and what is our outlook for our

testing capacity in the coming weeks and how that would increase where we are today to hopefully a level we'll be able to do comprehensive surveillance? >> so i'm going to have to get bacback to you about the hospitalization. i know it's a small number. i'll have to get the exact number. i'm not sure. >> and there's room for both of you. >> just to say that we are with other hospitals, working to get a daily count of how many patients are both covid positive and tuis and in what part of the hospital every single day. we aren't quite there and i know we have two at csfg and one of whom is in the icu. it's a small fraction of the 43. i don't know the numbers from the other hospitals today, but

in a couple of days, i will. >> and then just further to that, do we have a number for how many of our healthcare staff have tested positive? >> in san francisco, i'm only aware of two people that have tested positive, is my understanding. >> thank you. >> and then to the testing capacity and wer what the outlos before we're at a place we need to be. >> dr. kolfax will answer that later because he has all of the details about testing. >> thank you. other questions for dr. erogon before he has to leave? >> i just wanted to leave, doctor, in terms of, again, realizing supplies are in short, the working either with the

state or the feds to bring enough supplies and then some means of distributing it to the various providers that may need it. >> that goes to the equipment supply and the guidance yesterday that allows healthcare workers to use what's called a droplet precaution caring for patients. unless there's a procedure where there will be symptoms of virus and that will improve the ability to expand testing because they will have to use airborne precautions to collect specimens. >> thank you, doctor. >> that's county with what the cdc is recommending. >> i had one last question for dr. erogon before he has to leave. regarding the shelter in place

order through april 7th that's being sort of jointly issued by all of the six counties, what is the criteria that you might use to determine whether that is something that needs to be extended or is that just something that you're going to have to determine as you were saying, on an hour-by-hour or day-by-day basis, depending how this is playing out? >> so we had chosen to do three weeks and i can't imagine that in three weeks -- i imagine if we're moving -- if this epidemic continues to move in every placed it's been introduced, it may be worse and i think at that point, we're going to have to reassess both the city and the other counties to decide whether it needs to be extend. but that would be a decision we'll make closer to that time.

>> thank you. >> thank you, doctor. >> i think dr. kolfax will answer the testing question. >> i had a question before jail health and homeless population. >> there were a number of questions and please bear with me ibarebare withme.

i wanted to talk about hospital control and i don't know if you use that term, commissioner green. but i think that was the justice of it. gift of it. gist of it. i'm not so concerned about making sure that we're all reaching -- that we're all working together to reach our capacity as a community. what i'm concerned about when and if we exceed that capacity. i think that would take more of a -- if we reach that point, i would hope that before that, that the federal state authorities would have brought in assistance and whether that assistance could look something like the national guard or a military operation. we don't have the capacity right now to run something like that. that's not our mission.

with regard to that level of response and engagement. i just think those resources would be vital to that. and we do everything we can with our partners to do that in the interim. but i hope that we don't get to that situation. and i don't know commissioner green or others if you had any response to my response. >> i think when you think of things like we have two empty hospitals in our midst and if we ever needed one of these kind of mid-level quarantine sites as they used in china, the national guard and others might come and help us. but within our walls, we could know some of the resources, resterespirators and i'm curiouw

we can work together if it got to that. , whether that would be something that would fall under the hospital or elsewhere. there's other resources we might know about that they may not. >> we're looking at all of those option. i was thinking more of a massive icu means, which, i think we would have to look at hospitals in the bay or something like that. so again, i don't want to create an alarming scenario, but in terms of looking at other places where people who are not acutely ill but are symptomatic and stay, that's something we're looking at, not only with other hospitals but other key participanteners in the city. ps in the city. there was a question around testing. sohe