COVID - 19 INFORMATION AND RESOURCES
Data updates in Connecticut

Since March 21, an additional 104 Connecticut residents have tested positive for COVID-19, bringing the statewide total to 327. To date, more than 3,600 tests have been conducted in Connecticut among both state and private laboratories.

A county-by-county breakdown includes:

COUNTY

Fairfield County
Hartford County
Litchfield County
Middlesex County
New Haven County
New London County
Tolland County
Windham County
TOTAL
CONFIRMED CASES

208
54
12
6
29
3
14
1
327
DEATHS

5
1
0
0
0
0
2
0
8
Three more Connecticut residents died from complications of COVID-19, bringing the total number of deaths in the state to eight. They include:

  •  A man in his 80s who was a resident of a nursing home in Stafford Springs and recently hospitalized at Johnson Memorial Hospital (not to be confused with another man in his 80s who was also a resident of a nursing home in Stafford Springs and being treated at the same hospital, whose passing was reported in yesterday’s update);
  • A woman in her 80s who was a resident of a private home in Rocky Hill and recently hospitalized at Hartford Hospital; and
  • A woman in her 80s who was a resident of a private home in New Canaan and recently hospitalized at Norwalk Hospital.

For several additional charts and tables on testing performed in Connecticut, including a town-by-town breakdown of positive cases in each municipality, visit  ct.gov/coronavirus   .
State received more than 100 responses since launching request for Personal Protective Equipment

The Connecticut Department of Public Health (DPH) partnered with United Way of Connecticut to collect responses from those willing to make donations. Anyone who has these vital materials and would like to donate them to Connecticut’s medical community should fill out the online form located at  www.211ct.org/DonationsCOVID19  .

Requests received are being reviewed by staff at DPH and United Way to ensure that the donations meet the needs of  Connecticut’s medical community  . Items being requested by the state at this time include:
  • N95 Respirators
  • Face Masks/Surgical Masks
  • Face Shields
  • Surgical Gowns
  • Gloves (nitrile, or non-latex)
  • Thermometers
  • Thermometer Covers (if applicable to type of thermometer)
  • Hand Sanitizer
  • Other Medical Items
To possibly receive items for use in your medical practice send a request to:      Covid19.JIC@CT.GOV
Update regarding the management of patients with diagnosed or suspected COVID-19 receiving chronic treatment with blockers of the renin-angiotensin-aldosterone system (RAAS Blockers)

March 18, 2020
 
Dear Colleagues:
 
I am writing to provide an  update regarding the management of patients with diagnosed or suspected COVID-19 receiving chronic treatment with blockers of the renin-angiotensin-aldosterone system (RAAS Blockers).
 
Special thanks to Drs. Aldo Peixoto, Daniel Jacoby, Tariq Ahmad, Maricar Malinas, Nihar Desai, Eric Velazquez and Erica Spatz for the research they did leading to the below.
 
Sincerely,
  
Thomas Balcezak, MD
Chief Clinical Officer
Yale New Haven Health
 ----------------------------------------------------------------------------------------------------------------------------
Situation  : New data and recommendations from governing cardiology societies have changed perspective regarding use of RAAS antagonists in patients with COVID-19.
 
Background  : Concern has arisen regarding the potential effects of ACE and/or ARB use in the setting of suspected or confirmed COVID-19. An SBAR released on March 14  th  outlined recommendations in response to these concerns. On March 17  th  , a joint statement from the Heart Failure Society of America (HFSA), the American College of Cardiology (ACC), and the American Heart Association (AHA) was released specifically addressing this topic. The Statement acknowledges uncertainty regarding the potential effects of ACE and/or ARB use in the setting of COVID-19, and that recommendations are shifting in response to emerging data. The full statement is available at:  https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19  . 
 
Assessment  : The joint recommendation from the cardiology societies supersedes the notice sent out by the Office of the Chief Clinical Officer on March 14. The summary statement for these recommendations is as follows:
 
Do not add or remove any RAAS-related treatments, beyond actions based on standard clinical practice.
 
Recommendations  :
  1. The recommendations in the prior SBAR on this topic released on March 14th, 2020 to hold RAAS antagonists in the setting of COVID-19 are out of date and should not be followed.
  2. RAAS antagonists should be continued for patients currently prescribed such agents for indications for which these agents are known to be beneficial, such as heart failure, hypertension, or ischemic heart disease.
  3. In the event patients with cardiovascular disease are diagnosed with COVID-19, individualized treatment decisions should be made according to each patient's hemodynamic status and clinical presentation. 

March 22, 2020
 
Dear Colleagues,

The data from around the world make it clear that COVID19 poses disproportionate risk of morbidity and mortality for certain individuals.

Protecting the safety of our front-line clinicians to the highest degree possible is critical for our country to weather this crisis with the least possible damage. Our front-line healthcare workers are all at some risk as they care for our patients. We must do what we can to mitigate risk wherever possible, and in some cases redeploy those at highest risk to alternative work arrangements.

Guidelines for approaching clinicians at elevated risk in this crisis are included. Many thanks to a large group of leaders, including Drs. Lynn Tanoue, Saad Omer, Richard Bucala, Insoo Kang, Paul Taheri, Richard Goldstein, Joseph Quaranta, Prathibha Varkey, Mark Russi and others, and YNHHS Chief Human Resource Officer Kevin Myatt for working thoughtfully to develop these guidelines.

Best,
 
Thomas Balcezak, MD
Chief Clinical Officer
Yale New Haven Health
 
----------------------------------------------------------------------------------------------------------------------------
YNHHS/YM guidelines for approaching front line clinical practitioners with elevated risk of contracting COVID19
 
Situation:       Guidance is required to manage the safety of front-line clinical practitioners at elevated risk of morbidity and mortality if infected with SARS-CoV2, the virus that causes COVID-19 
 
Background:       COVID-19 poses a disproportionate risk of morbidity and mortality to individuals 70 years old and over, and those with select pre-existing conditions.
 
Assessment:
 
  1. The risk of mortality posed by COVID-19 is sharply increased for those who contract the virus SARS-CoV2 in their 8th decade of life or are otherwise immunocompromised.
  2. We have an obligation to our front-line clinical practitioners to mitigate undue risk.
  3. There are opportunities for clinicians to meaningfully contribute to COVID19 crisis management that do not require being physically present with patients.
  4. The data on elevated risk posed by COVID19 to specific populations are clear.
 
    Recommendations for inpatient and ambulatory providers:
 
  1. Leadership must identify practitioners 70 years old and over and speak directly to them. Leadership may also request that front-line practitioners self-identify as high risk based upon immunocompromised state or conditions with disproportionate risk for COVID.
  2. Honest & direct communication with front-line practitioners is critical.
  3. Practitioners aged 70 and over should be barred from direct (physically present) patient care in a mandatory fashion.
  4. Practitioners with serious medical illness or immunocompromised status (abbreviated definition below) should be excluded from direct (physically present) patient care in conversation with leadership, and Occupational Health as required.
  5. Those who are or may be pregnant should discuss risks with their obstetrician and leadership with regards to being in the physical presence of patients.
  6. Those excluded from the physical presence of patients should be redeployed to provide patient care through telemedicine or other activities where their expertise can materially benefit the care of patients and management of the COVID19 crisis.
  7. These guidelines will not adequately cover all situations and leaders have latitude to make shared decisions with their clinicians based upon unique situations that may arise.
 
Considerations on COVID-19 and Immunocompromise
Insoo Kang & Rick Bucala
Section of Rheumatology, Allergy & Immunology, Yale School of Medicine
 
Immunocompromise or immunodeficiency can be divided into two groups, primary and secondary.
  • Primary immunodeficiencies: severe combined immunodeficiencies, primary antibody deficiencies, and other forms of genetic disorders associated with impaired immune function.
  • Secondary immunodeficiencies: acquired secondary to infections (HIV), hematopoietic malignancies, treatment with radiation, chemotherapies, and immunosuppressive drugs.
 
The following circumstances are some but not all examples of immunocompromise based on the Advisory Committee on Immunization Practices (ACIP) guidelines for vaccination (1) (with some modifications)

  • Recombinant human immune mediators or biologics that block cytokines, immune activation molecules, or deplete cells (e.g., adalimumab, infliximab, golimumab, certolizumab, etanercept, anakinra, tocilizumab, secukinumab, ixekizumab, ustekinumab, alefacept, abatacept, rituximab).
  • Active leukemia, lymphoma, malignant neoplasms affecting bone marrow or lymphatics
  • AIDS/HIV patients and those with CD4 lymphocyte counts <200 per mm3
  • High dose glucocorticoids > prednisone 20 mg/day for more than two weeks (dose can be disputed; in rheumatology 10 mg or lower is typically considered as low-dose glucocorticoids).
  • Clinical or laboratory evidence of cellular or humoral immunodeficiency
  • Hematopoietic stem cell transplantation.
  • Pregnancy
  • Non-biologics immunosuppressive drugs including small molecules (e.g. azathioprine, cyclosporine, tacrolimus, mycophenolate, 6-MP, high dose methotrexate (>0.4 mg/kg/week), cyclophosphamide, tofacitinib, baricitinib, upadacitinip).
 
What is the impact of immunosuppressive drugs on the risk of infection or poor outcomes with COVID-19?    
  • It may or maybe not increase the risk of infection or adversely affect outcomes. The morbidity of COVID-19 appears be largely related to excessive immune activation, inflammation, and sepsis (2). Some biologics like TNF-α blockers may lower risk of sepsis or death at the time of infection (2, 3).   Of interest, a recent comment published in The Lancet Infectious Diseases suggests the possible antiviral effect of the Jak inhibitor baricitinib in COVID-19 by suppressing clathrin-mediated endocytosis and a combination of this drug with other direct antiviral agents (lopinavir or ritonavir and remdesivir) for COVID-19, which could reduce viral infection, replication, and dysregulated host inflammation (4). Also, in China, the IL-6 receptor blocker tocilizumab has been approved for COVID-19-infected patients with severe complications, and a clinical trial has been initiated (5). Thus, some immunosuppressive drugs such as tocilizumab and baricitinib with anti-inflammatory properties may be clinically beneficial in selected cases of COVID-19 while others may increase the risk of infection or adverse outcomes.
  •  It should nevertheless be emphasized that in a multivariate model of COVID-19 hospitalized subjects, advanced age was the primary risk factor for mortality among cases, irrespective of comorbidities such as hypertension, diabetes, COPD, and others (6).
 
References
  1. R, Ortega-Sanchez IR, Seward JF, Advisory Committee on Immunization Practices Centers for Disease C, Prevention. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1-30; quiz CE2-4.
  2. Winthrop KL. Who needs a Corona? Arthritis & Rheumatology. 2020;In Press.
  3. Richter A, Listing J, Schneider M, Klopsch T, Kapelle A, Kaufmann J, et al. Impact of treatment with biologic DMARDs on the risk of sepsis or mortality after serious infection in patients with rheumatoid arthritis. Ann Rheum Dis. 2016;75(9):1667-73.
  4. Stebbing J, Phelan A, Griffin I, Tucker C, Oechsle O, Smith D, et al. COVID-19: combining antiviral and anti-inflammatory treatments. Lancet Infect Dis. 2020.
  5. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. The Lancet. 2020;published on-line 11 March 2020.
  6. Worldometer: COVID-19 CORONAVIRUS OUTBREAK. Accessed on March 8, 2020 at 6.15 pm EST from: https://www.worldometers.info/coronavirus/
  7. The update of COVID-19 in ROK (March 8, 2020). Accessed on March 8, 2020 at 6.15 pm EST from: https://www.cdc.go.kr/board/board.es?mid=&bid=0030
  8. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China. JAMA. Published online February 07, 2020. doi:10.1001/jama.2020.1585.
  9. Wang, W, Tang, J, Wei, F. Updated understanding of the outbreak of 2019 novel coronavirus (2019nCoV) in Wuhan, China. J Med Virol. 2020; 92: 441– 447. https://doi.org/10.1002/jmv.25689.
  10. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DS, Du B. Clinical Characteristics of Coronavirus Disease 2019 in China. NEJM. 2020 Feb 28.
Department of Economic and Community Development launches COVID-19 business response unit

The Connecticut Department of Economic and Community Development (DECD) is launching the COVID-19 Business Emergency Response Unit, which will be dedicated to helping businesses in Connecticut navigate the resources available to them during this crisis. Medical practices seeking guidance can reach this unit by calling 860-500-2333
Business Resources Available to Medical Practices

Many medical practices are struggling during this unprecedented Coronavirus pandemic and may be wondering if they can remain in business.
 
There are many resources available to businesses that medical practices may be able to take advantage:

If you're a medical practice that is struggling, you may be able to find suitable assistance to help get through this crisis.
CT Department of Labor (DOL) Unemployment Assistance

Workers directly affected by the coronavirus pandemic no longer must be actively searching for work to qualify for   unemployment assistance   . Additionally, employers who are furloughing workers can use the Department of Labor’s  shared work program   , which allows businesses to reduce working hours and have those wages supplemented with unemployment insurance.
Connecticut Department of Labor modifies unemployment insurance, offers programs

Connecticut Department of Labor (CTDOL) is suspending the requirement that workers applying for new unemployment benefits directly impacted by the COVID-19 pandemic be actively searching for work.

Unemployment benefits are available to workers whose employer needs to temporarily shut down or slow down business. Employees who are furloughed by the emergency but expect to return to work can access up to at least six weeks of benefits.  Employers reducing hours but not furloughing employees can partner with CTDOL’s Shared Work program, which allows employers to reduce employees’ work schedules by 10 percent to 60 percent and supplement lost wages with unemployment benefits.

Connecticut unemployment insurance already excluded the waiting period other states have removed.

For a document containing a list of Frequently Asked Questions for workers and businesses regarding unemployment insurance during the COVID-19 outbreak,  click here
Office of Early Childhood working to ensure childcare for healthcare staff and first responders

Our communities rely on child care providers to support families, particularly those who play a critical role during this public health emergency. The Connecticut Office of Early Childhood (OEC) is working to make child care available for  healthcare staff and first responders   in particular. On Monday, OEC posted 37 waivers for child care facilities in order to ensure child care is flexible. The agency is actively working with several hospitals to provide stand-up child care for their workers and hopes to expand this effort.

Families are encouraged to look to trusted friends, neighbors and family members, who are not in a high-risk category - for child care. Anyone in need of child care is encouraged to dial 2-1-1 and they will be directed to resources in their area.

OEC is sending out guidelines today to child care programs and families throughout the state to help ensure everyone remains safe during this period.
Governor Lamont’s  Executive Order No. 7I   enacts the following provisions:

  • Modifications to DSS benefits
  1. Suspension of copayments for full benefit dually eligible Medicare Part D beneficiaries
  2. Suspension of copayments for HUSKY B clients
  3. Suspension of limitations on refills of non-maintenance medications for HUSKY beneficiaries
  • Modifications to Department of Consumer Protection (DCP) regulations regarding pharmacies
  1. Provides pharmacists the ability to refill non-controlled substance prescriptions for up to 30 days in the event they are unable to contact the prescribing practitioner
CMS Announces Relief in Quality Reporting Programs in Response to COVID-19

The Centers for Medicare & Medicaid Services (CMS) is supporting clinicians on the front lines by getting red tape out of the way so the healthcare delivery system can focus on the 2019 Novel Coronavirus (COVID-19) response.
CMS is implementing additional extreme and uncontrollable circumstances policy exceptions and extensions for upcoming quality measure reporting and data submission deadlines for the following CMS programs:
Provider Programs

Quality Payment Program - Merit-based Incentive Payment System
(MIPS)

Medicare Shared Savings Program Accountable Care Organization (ACOs)

2019 Data Submission

Deadlline extended from March 31, 2020 to April 30, 2020

MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020 will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year.
2020 Data Submission




CMS is evaluating options for Providing relief around participation and data submission for 2020
2019 MIPS Automatic Extreme and Uncontrollable Circumstances Policy Update

MIPS eligible clinicians who have not submitted any MIPS data by April 30, 2020 do not need to take any additional action to qualify for the automatic extreme and uncontrollable circumstances policy. These clinicians will be  automatically  identified and receive a neutral payment adjustment for the 2021 MIPS payment year.

CMS will continue monitoring the developing COVID-19 situation and assess options to bring additional relief to clinicians and their staff so they can focus on caring for patients. 

For More Information

Please reference the  2019 QPP Data Submission User Guide   . CMS also has up to date information about its programs and response to COVID-19 on the  Current Emergencies   page.
For Quality Payment Program questions you can contact 1-866-288-8292   , Monday through Friday, 8:00 AM-8:00 PM ET or by e-mail at:   QPP@cms.hhs.gov   .
As blood drives have been canceled, Red Cross of Connecticut asks donors to schedule appointments

To mitigate the spread of the virus and reduce gatherings of large groups of people, the American Red Cross has canceled nearly 2,700 blood drives throughout the country. More than 80 percent of the blood the Red Cross collects come from donation drives, and these cancellations have resulted in some 86,000 fewer blood donations.

The Red Cross of Connecticut is asking people in the state to consider donating blood by calling ahead to one of their offices and scheduling an appointment that will allow them to encourage safe social distancing while still ensuring blood donations are being received.

Individuals interested in donating blood can schedule an appointment by visiting  RedCrossBlood.org   , using the  Red Cross Blood Donor App   , calling 1-800-RED-CROSS , or enabling the Blood Donor Skill on any Alexa Echo device.
SMB Networks , a FCMA affinity vendor and the company that services
FCMA's IT needs is offering free technology assistance to medical practices to help you with your remote access needs should your office need to work at home, for a limited time only or when their resources are depleted. You can contact the associations or learn details:  https://youtu.be/ts2G2yXKbVI

The SMB Support Team  can be reached at  Techhelp@smbnetworksllc.com  or
call Tel (203) 672-0202
WEBINAR

COVID-19 Billing for Telemedicine Services
Wednesday, March 25
12:00 pm to 1:00 pm

USEFUL LINKS

CT Controlled Substance Prescription Drug Refill Guidance

Connecticut Department of Public Health Human Infection with 2019 Novel Coronavirus Persons Under Investigation (PUI) and Case Report Form

Infection Prevention for Self-Quarantine   from Northwell Hospital



What you need to know as Coronavirus directly affects business supply chains, workers’ compensation, organized events and more.

Yes, a business can potentially be liable if an employee contracts coronavirus while working abroad or in the office.

USEFUL ARTICLES

Coronavirus Stable for Hours (NIH) 

The virus attacks the ACE2 receptors. Based off of SARS, it is possible that SARS2 likely infects type 2 alveolar cells. This research paper from a European lab group appears to confirm this notion. 

Nigeria records chloroquine poisoning after Trump endorses it for coronavirus treatment (CNN)

Simple Explanation of the coronavirus