Effective for dates of service on and after April 1, 2020, ForwardHealth, which has an expedited emergency supply policy dispensing option available for certain drugs, has expanded the list of drugs available through expedited emergency supply and will allow most drugs to be dispensed in up to a 100-day expedited emergency supply.

A table with the expanded list of drugs available by expedited supply is included below and is also available on the Pharmacy Resources page of the ForwardHealth Portal. Pharmacy providers should continue to follow the current processes for requesting an expedited emergency supply of drugs detailed in the Emergency Medication Dispensing topic (#1399) of the ForwardHealth Online Handbook.

This Action Alert 10 and others are available on the ForwardHealth website (link).

A new Marquette Law School poll of Wisconsin registered voters finds strong support for government actions to control the coronavirus pandemic, even as the poll also shows these actions to be having a substantial financial impact on voters.

The survey found:

• Eighty-six percent say that it was appropriate to close schools and businesses, and restrict public gatherings, while 10 percent say that this was an overreaction to the pandemic;
• A large majority of voters approve of Gov. Tony Evers’ handling of the coronavirus issue, with 76 percent saying they approve and 17 percent saying they disapprove;
• A majority, 51 percent, approve of President Donald Trump’s handling of the pandemic, while 46 percent disapprove;
• Opinion is divided on holding the April 7 spring election as scheduled, with 51 percent saying the date should be moved and 44 percent saying it should be held as scheduled.

A full copy of the survey is available online (link).

Wisconsin has received its second phase of Personal Protective Equipment (PPE) from the Strategic National Stockpile (SNS) and is in the process of distribution. The second phase of supplies from the SNS are being delivered to healthcare workers, emergency medical services, and medical facilities including hospitals, nursing homes, assisted living facilities and clinics across Wisconsin.

“We are doing everything we can to get more protective equipment as fast as we can to our healthcare workers and those on the frontlines to protect them from COVID-19,” said Gov. Evers. “We want to make sure our healthcare workers can continue doing their good work and taking care of our neighbors in communities across our state, and we are working to get these supplies to the folks who need them the most as quickly as possible.”

The State Emergency Operations Center and Department of Health Services continue working to supply medical facilities with supplies requested from the Strategic National Stockpile. The second phase includes approximately 51,880 N95 respirators, 130,840 face/surgical masks, 23,400 face shields, 20,226 surgical gowns, 96 coveralls, and 79,000 pairs of gloves. Today’s shipment comes as Governor Evers announced Wisconsin’s first delivery of SNS supplies which included approximately 52,800N95 respirators, 130,000 face/surgical masks, 24,768 face shields, 20,286 surgical gowns, 96 coveralls, and 61,750 pairs of gloves. In total Wisconsin has received approximately 104,680 N95 respirators, 260,840 face/surgical masks, 48,186 face shields, 40,512 surgical gowns, 192 coveralls, and 140,750 pairs of gloves from the SNS.

The SNS supply shipments do not include supplies the governor has requested from FEMA for non-medical personnel or supplies being aggressively pursued through procurement, donations, or the governor’s buyback program.

Governor Evers today sent a letter to the Federal Emergency Management Agency (FEMA) requesting that the president issue a major disaster declaration for the entire state of Wisconsin, as a result the COVID-19 pandemic. The request covers all 72 counties and the state’s federally recognized tribes.

Having determined that Wisconsin met all of the criteria required to receive a major disaster declaration, Gov. Evers in his letter requested that the federal government provide the following programs to support the state’s response: Public Assistance, Direct Assistance, Hazard Mitigation (statewide), and certain Individual Assistance programs; Crisis Counseling, Community Disaster Loans and the Disaster Supplemental Nutrition Program.

Gov. Evers declared a public health emergency on March 12 in response to the outbreak, which directed the Department of Health Services to take all necessary and appropriate actions to help combat the spread of the virus. On March 14, the governor directed Wisconsin Emergency Management to activate the State Emergency Operations Center (SEOC) to provide additional coordination in support of the state’s response.

A copy of the governor’s letter (link) and the full press release are available online (link).

Governor Evers today announced the State of Wisconsin Emergency Operations Center (SEOC) is opening two state-run voluntary isolation facilities in Madison and Milwaukee and is providing guidance to local communities throughout Wisconsin. The two sites are set to open April 1, 2020 are at Lowell Center in Madison and a Super 8 hotel in Milwaukee.

These facilities are for symptomatic individuals suspected to be infected with COVID-19 or who have a confirmed case of COVID-19. Individuals will not be permitted to register at the facility unless referred by a medical provider or public health official. Individuals register and stay at the isolation facility on a voluntary basis. The expected length of stay will be about 14 days, or 72 hours after symptoms dissipate. At any time, either the individual or the facility may terminate the individual’s presence at the site. Those staying at the facility will have wellness checks by phone every four hours during the day and if needed at night.

Additionally, the SEOC also issued guidance for communities seeking to open their own voluntary self-isolation centers. This guidance will aid local communities with the following:

How do we select, set up, and staff an isolation site?

How does a person get referred to and checked into the isolation site?

What happens while occupants are at the isolation site? Including details about medical monitoring/wellness check calls and other on-site services.

When do occupants leave the site? Including details about discharge and involuntary check out from the isolation site.

The full press release is available online (link).

The Wisconsin Partnership Program ​released an RFP​ Tuesday for a new $1.5 million grant program to support projects that “aim to improve the health of the people of Wisconsin by lessening the impact of the COVID-19 pandemic.”

 About $750,000 will be available for programs led by Wisconsin-based nonprofits, tax exempt, 501(c)(3) organizations or tribal/government entities. Special emphasis will be given to projects that target vulnerable populations.

Grant applications are due April 15, 2020.

Jeffrey Davis, ACEP Director of Regulator Affairs, shared the following details regarding the announcement of CMS policies including big wins for emergency medicine: 

• EMTALA: CMS issued the long-awaited revised guidance on EMTALA that will allow medical screening exams to be delivered via telehealth. This has been a major ACEP priority, and we repeatedly asked CMS to issue this revised EMTALA guidance. There are other temporary changes to EMTALA, and Dr. Todd Taylor will send a separate email explaining these. 
• Telehealth: CMS added the ED E/M codes (CPT codes 99281 to 99285) and the critical care codes (CPT codes 99291 and 99292) to the list of approved Medicare telehealth services for the duration of the COVID-19 national emergency. CMS had previously expanded the ability to perform telehealth services but had not allowed emergency physicians to use the ED E/M codes-which most accurately reflect the intensity and value of emergency services. ACEP had identified this issue as a top regulatory priority, and through ACEP's advocacy, CMS has now recognized that ED E/M codes are indeed the most appropriate codes to use when delivering emergency telehealth services.  
• Expanding the Healthcare Workforce: CMS is allowing hospitals to increase their workforce capacity by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community as well as those licensed from other states without violating Medicare rules. ACEP had urged CMS to relax state licensure requirements. 
• CMS Hospital Without Walls: CMS is allowing hospitals to provide services in locations beyond their existing walls to expand care capacity and to develop sites dedicated to COVID-19 treatment. Under CMS's temporary new rules, hospitals will be able to transfer patients to outside facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving hospital payments under Medicare. Ambulances will also be able to transport patients to a wider range of locations when other transportation is not medically appropriate. These destinations include community mental health centers, federally qualified health centers (FQHCs), physician's offices, urgent care facilities, or ambulatory surgery centers.  
• Waiver of Physician Self-Referral Law: CMS issued blanket waivers of sanctions under the physician self-referral law.  

These are only some of the many policies announced. ACEP is scheduling a webinar with CMS for Friday, April 3rd to discuss EMTALA. More details to follow.  

March 31, Wisconsin Health News

Assembly Speaker Robin Vos, R-Rochester, said Monday that the Legislature will act on a request by the Department of Health Services to waive Medicaid rules in response to COVID-19. 

DHS plans to pursue an emergency 1135 waiver from the federal Centers for Medicare and Medicaid Services. It needs legislative approval to do so under a law enacted after Gov. Tony Evers was elected, but before he took office.

Vos said the Assembly hopes to hold a floor session soon and they’re exploring ways to convene it without “adversely impacting” at-risk populations within their membership and support staff. 

He’s also expecting a final analysis from the Legislative Fiscal Bureau on the federal stimulus law approved last week. 

“We know legislative action will need to be taken, including a request for an emergency waiver from CMS to allow for flexibilities to healthcare providers,” Vos said in a statement. 

He added that they’re having daily discussions with the governor’s office and legislative Democratic leaders. 

DHS officials submitted a request for an emergency waiver to the Legislature’s Joint Finance Committee last week. Spokesman for the committee's leaders said they don't have authority to act on the request.

Evers on Monday called on the Legislature to allow for “greater flexibilities within the Department of Health Services so they can act rapidly and ensure folks are getting the care they need without any unnecessary barriers such as pre-authorization requirements.”

“Lives are on the line here, and we can’t afford being hamstrung by bureaucratic hurdles,” he told reporters.

Governor Evers announced a new public-private partnership among Wisconsin industry leaders to increase Wisconsin's laboratory testing capacity for COVID-19. Prior to today's announcement, the Wisconsin State Lab of Hygiene and the Milwaukee Public Health Lab were leading the Wisconsin Clinical Lab Network labs to bring additional COVID-19 testing online.

The new partnership now includes laboratory support from Exact Sciences, Marshfield Clinic Health System, Promega, and UW Health. These organizations, along with the Wisconsin Clinical Lab Network, will now share knowledge, resources, and technology to bolster Wisconsin’s testing capacity.

The Wisconsin Clinical Lab Network labs have been averaging completion of 1,500-2,000 COVID-19 tests per day. The expanded capacity from the state’s new public-private partnership is expected to double that capacity initially and continue to expand as additional platforms and supplies become available.

Residents who are seeking a COVID-19 test are still required to receive an order from a doctor. These labs are not testing sites. 

The full press release is available online (link).

Andrew Cathers, MD
Associate Medical Director, UW Med Flight
Univ. of WI BerbeeWalsh Dept of Emergency Medicine

UW Med Flight has established an ECMO Transport Program.  Through close partnerships with UW Health’s Critical Care and Cardiothoracic Surgery teams, Med Flight has been able to devise and implement a program wherein these critically ill patients can be safely transported.  In addition, in select situations, the team can travel to the patient, cannulate them at a referring facility, place them on ECMO, and then transport them back to UW Health.

Extracorporeal Membrane Oxygenation (abbreviated as ECMO), is a treatment that is becoming steadily more widespread and prevalent.  It is typically used for patients with severe cardiorespiratory illness.  There are two primary variants – veno-venous (VV) and veno-arterial (VA).  VV ECMO is typically used in patients with intact cardiac function but severely compromised respiratory function, such as ARDS.  VA ECMO is used for patients in cardiac arrest or severe circulatory shock, with the ECMO device supporting both the heart and the lungs.  Typically, large-bore cannulas are placed in the central vessels, and then an ECMO pump and circuit is utilized, which will circulate and oxygenate the blood.  As technology advances and ECMO transport has become more common, the ECMO devices themselves have become smaller and some are even specifically designed for ease of transport in mind.

ECMO has traditionally only been initiated and maintained in large, tertiary centers.  However, recent advances, including more widespread use of percutaneous cannulation techniques, have seen ECMO use spread to the smaller hospitals.  Many of these hospitals lack the capability to longitudinally care for ECMO patients.  In other cases, patients are placed on ECMO in order to “bridge” them to further treatment, such as Ventricular Assist Device placement or lung transplant.  Because of this, these critically ill patients often need to be transferred from the smaller facility to the destination center.  Finally, there are critically ill patients at outlying facilities who may not survive conventional interfacility transport – in these cases, it is actually safer for the patient if they are cannulated and supported by ECMO prior to moving between facilities.

Our teams have completed ECMO transports via both helicopter and ground ambulance.  Mode of transport is flexible and dictated by distance, weather conditions, and most importantly – the needs of the patient. 

Team

• Board-Certified Emergency Medicine Physician with additional transport and ECMO training
• Critical Care Registered Nurse with additional transport and ECMO training
• Board-Certified Cardiothoracic Surgeon with ECMO expertise
• Perfusionist

Vehicle

• EC-145 Helicopter
• Critical Care Transport Ambulances

Patient Population

• Adult Patients already on VA or VV ECMO – either centrally or peripherally cannulated
• Adult Patients who are not yet on ECMO but may benefit from this intervention who are at an outside facility