California providers scrambling amid fires, heat waves, COVID-19 — and now blackouts

• California fires, heat waves, power outages and a COVID-19 surge are complicating the care of chronically ill patients in the state.
• Home settings have shortages of adequate air conditioning and power for critical medical equipment.
• Providers need to gauge which telehealth patients may need urgent in-person triage.

“I look out my window and it’s just massive haze; you know that there’s just smoke everywhere,” Pat McGinnis, executive director of California Advocates for Nursing Home Reform, said Monday.

Her office is located in San Francisco, where none of the hundreds of California wildfires are active. But that doesn’t keep smoke from fires in other counties from rolling in and affecting the air quality. On Aug. 25, California had 624 active wildfires, including 17 considered major conflagrations, according to published reports.

The danger from smoke and fire is just one of the many challenges that seniors and chronically ill patients — and their healthcare providers — face in a state wrestling with a continuing surge in COVID-19 cases and a heat wave. The latest challenge is blackouts, including the first unplanned large-scale power outage in nearly 20 years, due to a lack of power sources.

Nearly 2 million residents lost power Aug. 14, and the fires have led to numerous smaller-scale outages as power lines endangered by wildfires or in areas prone to lightning strikes were shut off.

“We certainly have rolling blackouts this year,” said Jeannee Parker Martin, president and CEO of LeadingAge California, which represent 675 skilled nursing facilities, home healthcare companies and retirement communities.

Some member-organizations of LeadingAge lost power from the fires last week and had to rely on generators, Martin said. Most of the organizations, especially the larger ones, had air conditioning available.

Access to sufficient air conditioning and exposure to the large amounts of smoke — even in areas without nearby fires — were “really critical” concerns for the senior and chronically ill populations cared for by members of LeadingAge California, she said. The smoke has been thick enough for the last four days in San Francisco to block out the sun, except out over the ocean.

“That is a very real issue right now — the combination of the smoke and the heat and breathing problems,” Martin said.

The fires also have directly affected provider facilities.

So far this summer, at least five of Martin’s member-organizations have prepared for possible evacuations after they were included in fire-evacuation warning zones. Ultimately only one, in Fairfield, where a fire jumped an interstate highway, had to partially evacuate for a short time.

And on Aug. 19, Cal Fire issued a mandatory evacuation order for Adventist Health St. Helena Hospital in Napa County.

Home-based patient challenges

The confluence of environmental hazards and electrical shortages — or a lack of air conditioning — could create challenges for sicker residents living independently, Martin said. For instance, opening windows can alleviate hot interior temperatures, but that’s not an option with the heavy smoke.

McGinnis noted that the masks used to prevent the spread of COVID-19 are ineffective at preventing smoke inhalation from the wildfires.

“People are trying to stay inside for air-quality reasons and of course we’re social distancing, but for people who don’t have adequate cooling in their house, that can create a huge danger,” said Leah Witt, MD, geriatrician and pulmonologist at UCSF Health and an assistant professor of medicine at UC San Francisco.

Patients with chronic lung disease also are wary of using cooling centers, which provide emergency air conditioning to residents, because of concerns about contracting COVID-19.

Patients with chronic breathing conditions also are endangered by the power outages because many of them depend on stationary air concentrators that lack battery backup power, Witt said. Fire-related outages can last days, but even those that last only a few hours create risk and anxiety among those dependent on plug-in-powered equipment.

The added worry can be even more problematic for residents who already are feeling the effects of months-long home social isolation.

“It feels oppressive and really anxiety-producing — and it’s not just exacerbations of their chronic disease, but it’s just the mental toll that all of this is taking,” Witt said.

What providers can do

Witt makes sure to ask her patients at the pulmonary clinic about steps they are taking to avoid the numerous environmental risks, including:

• Whether they’re staying inside and avoiding going out
• Whether it’s cool inside
• How they’re obtaining groceries
• Whether they’re feeling isolation, anxiety or depression

Like many providers, Witt is using telehealth much more extensively due to COVID-19. Beyond reducing the risk of COVID-19 exposure, telehealth decreases exposure to heat and smoke inhalation among chronically ill patients.

However, she worries telehealth may prevent her clinic from conducting in-person visits with those who need them. She urges those with shortness of breath, for instance, to come for in-person care so she can perform triage.

 “It’s really tough for a lot of our patients because they have an understandable fear about leaving the house and they want to be safe and socially distanced,” Witt said. “But we also want to make sure that their chronic health conditions are being adequately cared for in the midst of the terrible air quality and the pandemic.”