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 ill start with you, commissioner. role call . Well 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 directors report. The directors report is in front of you and i would ask that if you have any questions, of course, im happy to answer them, but given that the majority of our meeting with focus on covid19, i will not need whats in front of you, but im happy to answer any questions you see fit to raise at the time. Any commissioner questions . Im 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. Im 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 theres a delay. I think its just the microphone distance. Other things are clear. Can you hear me commissioners . Is that better . Yes, thank you. Thank you. So good afternoon, im the director of health and i want to say how much i appreciate the social distancing intervention were approaching today and not to make light of the historic moment were 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, im 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 thats emerging from china and italy, we know that about 80 of people do well. I will say the patterns are what evacueweve 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 its important to emphasize this was done for the first time, to my knowledge, as a joint Public Health ordinance. Its 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 statewide and nationwide. As weve seen the virus increasing its spread in various communities and countries, the direction has only been further escalation of efforts. Im 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 were 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 were 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, im 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 im going move and dr. Erogon will come in front of the camera and well switch back again. Does that make sense . Yes. Thank you, director. Im going to be brief because theres 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 were having to make decisions, in a matter of hours. And so, what we have had to do is not just see whats happening in other parts of the world but whats 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 theres 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. Stheres isolation toronto and e of contact. Youve 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 well get a a good proportion of the population will get infected and from the recent data up to 80 will become infected. Thats why this is so infectious is because theres 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 youre spreading it out so it doesnt 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. Its suppression and it turns out were implementing suppression and implementing the most aggressive approach. And thats where were trying to get the reproductive number less than one and the way pause . The way that were 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, theyre 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 youre asking people to stay unexpose bid staying at hole, youll 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 dont want to be in our shoes. If youre 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 wont 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 youre seeing is just the tip of the iceberg. This iceberg, youre only seeing the tip and that iceberg doubles every six days. That iceberg doubles every six days and thats why you have this explosion. If nno one can see it coming and thats why we have to be aggressive and be ahead of the curve. Theres other orders in there that were 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 its been great in getting the support. Weve 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 were in an incredibly unusual time, very unpresprecedented iny professional carr career and i l grateful to be a part of the department because were 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, weve been meeting regularly with the San FranciscoHospital Council ceos and also with their medical nursing and operational leaders. There arent 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. Its 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 were trying to do is redeploy the resources that were used in those services into more covidrelated 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, were 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 were 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 dont yet have the data for all of the hospitals, i cant tell you what that level is today. I have a pretty good idea, based on the discussions that weve been having and what our own level is. Today, theres 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. Theyre 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 arent yet filling it. So thats the question we are at now. Tthe other thing i can tell you thats exciting, were looking to see beyond the capacity, in our individual hospitals, what capacity we utilize in hospitals that have vacant beds that arent staffed. And weve 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 were in the process of seeing what it would cost to staff it. In general, were looking at a model whereby the basic support services are covered by st. Francis and were looking at registries, essentially, to fill the nursing positions and then a shared model of Provider Services between dignity ucsf and ucsfg. Im happy to answer any other questions. Theres a lot of detail i havent covered by im 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. Lets do person by person. Dr. Chow, you had some questions and would you like to start . Thank you. Im really appreciative of all of the work thats been done. Weve 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, im pleased that weve 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 weve 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 cant do it alone and i know the department is trying to respond to it and just was interested. Thats a large segment of the potential medical providers that, if they dont have the resources, that we dont 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 ill let dr. Kolfax speak to that. Commissioners, it might ask people in seat to ask all of the questions we have so were not playing musical chairs. How about we ask dr. Erlich call of the questions we have in her topic area, with your permission. Thats 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, im 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 were 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 covidpositive patients. And so were all informing one another and talking about the measures that were taking, which are pretty similar. With respect to that centralized resource at st. Francis, i think the idea is this threepronged approached that i described, whereby st. Francis is looking at what its going to cost to provide the basic supplies and the basic support Services LikeEnvironmental Services and food. And were looking jointly at registry resources that were trying to see if it can be made available to provide the nursing and clinical staff, nonprovider staff and then were looking at a shared Services 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, were oing on seeing if we can get the resources available, putting aside the question of whos going to pay for them and figuring out how we can jointly put providers in there for about 48 patients. This is really a daybyday thing. So its really the surge plan that will tell us when were ready to occupy. The last part of we keep hearing the audio go in and out, so i didnt catch the last couple of sentences. I think what were 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, ill pull that trigger. You know, were really working that out. But the way weve 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 thats innovative and forwardthinking. I also saw that were 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 youre only talking about 40 or 50 beds. Right. So the big question in all of our minds and the other thing were 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, well 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 were 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. Weve asked them to model this question for us. How many beds will we need, of what type, what period of time . And so hopefully, ill 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 wel 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, wh