Clinical Care During COVID-19

In February 2020, Department Chair Gary V. Desir, MD, and Vice Chair of Clinical Affairs Lynn Tanoue, MD, MBA, began hearing from colleagues at the University of Washington in Seattle and the major medical centers in New York City that the influx of COVID-infected patients was straining the medical services at their institutions. Desir and Tanoue began to plan for the imminent arrival of the pandemic in Connecticut.

They assembled a department leadership team that began discussing how to reorganize in-hospital and outpatient care and education to balance quality, efficiency, sustainability, and risks. They identified key operational issues that required immediate attention and started planning their response.

Planning for Patients

Concerned about her colleagues’ experiences at other institutions, Tanoue drafted a plan for a dramatic reorganization of in-hospital care for the internal medicine service.

Desir called a meeting on Sunday, March 8, with Tanoue and Vice Chairs Aldo Peixoto, MD, and Vincent Quagliarello, MD, to draw up plans for reorganization. They also discussed worst-case scenarios and plans for responses to a variety of potential critical situations among the department clinicians.

And so it began. Department leaders, section chiefs and program directors began daily COVID meetings. One week later, the first patient with confirmed COVID-19 entered Yale New Haven Hospital (YNHH). Many clinicians, educators, researchers, trainees, and staff rose to battle the pandemic.

At the VA Connecticut Healthcare System (VACHS), some actions mirrored what happened at the Yale School of Medicine (YSM) and YNHH, though others were different. One of the first steps taken was the creation of the Incident Command Center (ICC), which included leaders across the facility to prepare for the response to COVID-19. The ICC met on a daily basis to create policies, review issues, and provide resolutions in real time. The work at VACHS was led by Daniel Federman, MD, interim chief of medicine, and Michael Kozal, MD, chief of staff and a renowned virologist. Secretary of Veterans Affairs Robert Wilkie Jr. came to VA Connecticut in October 2020 to recognize the outstanding efforts of VACHS. Shaili Gupta, MBBS, became the COVID Response Coordinator for the Department of Medicine, VACHS. Additionally, Kathleen Akgün, MD, MS, BS, was named co-chair of the Scarce Resource Allocation Committee, newly formed to respond to COVID-19.

Physical Changes

While the staffing models were evolving, physical changes were also introduced at both YNHH and VACHS. On March 8, VACHS started performing active screening at its main entrance to identify patients who might have been sick or infected by the disease. The number of elective procedures at YNHH was decreased starting the week of March 16, in order to conserve personal protective equipment (PPE) and free up hospital resources. This change reduced the number of elective patients admitted into the facility, and enabled the relocation of services that might not have been possible if the facility had remained at its usual high census.

In ordinary circumstances, the YNHH Medical Intensive Care Unit (MICU) has a capacity up to 40 beds on the York Street Campus and 16 at the Saint Raphael Campus, with up to 20 negative pressure rooms across both campuses. It became quickly apparent that many more negative pressure rooms and more ICU beds would be needed. The goal was to maximize the available number of these rooms, which are critical to reduce the transmission of such infectious diseases as COVID-19, as well as increase the number of critical care beds to allow safe management of critically ill COVID-19 patients. Jonathan Siner, MD, clinical chief for Pulmonary, Critical Care and Sleep Medicine (PCCSM), and medical director of the MICU, was in charge of the critical care reorganization for the health care system and worked with YNHH leadership to develop a plan to expand the MICU capacity. Because the top three floors of the North Pavilion (NP) of Smilow Cancer Hospital/Yale Cancer Center (YCC) were all built in such a way that the rooms could be converted to negative pressure rooms when needed, the team decided to convert these floors into COVID critical care units.

On March 18, medical and surgical oncology patients were relocated from the top three floors of the NP of SCH/YCC so that the ventilation system on those floors could be changed to some degree of negative pressure to care for COVID-19 patients. The North Pavilion was designed after the SARS epidemic with the foresight that NP-15, NP-14, and NP-12 could be converted as a stack of floors to provide a negative pressure environment.

The transformation of these units into COVID-19 ICU floors led to moving medical and surgical oncology operations to the Saint Raphael Campus (SRC). Moving these lines of service was orchestrated in less than a week by Smilow’s operations medical leadership: Kevin Billingsley, MD, MBA; Kerin Adelson, MD; Elizabeth Prsic, MD; Thomas Prebet, MD, PhD; and nursing under the leadership of Kim Slusser, MSN, RN. The conversion of these floors resulted in an additional 84 critical care-capable patient beds, which began to receive patients on March 27. As inpatient volume grew, additional units were transformed. By April 20, 16 of the 27 units at the York Street Campus (YSC) and 11 of the 18 units at SRC were dedicated COVID-19-positive spaces, in which patients could be safely cared for without endangering others who didn’t have the disease.

At the height of the pandemic in the spring of 2020, clinicians, respiratory therapists, and nurses in the MICU cared for 120 patients across both YNHH campuses. Additionally, medical critical care teams collaborated with the leadership of the other YNHH specialty ICUs to provide care for both COVID-19 patients and non-COVID-19 medical critical care patients in the surgical ICUs and operating rooms during this time.

Prior to COVID-19, VACHS had 34 total negative pressure rooms. To prepare for the influx of patients, personnel converted entire wings and floors to negative pressure rooms, which resulted in an extra 20 beds. In addition, four COVID-19 units were created. The ICU and on-ward policy of care was devised and revised in real time to continue state-of-the-art management of COVID-19 patients with a multidisciplinary team approach involving general medicine, cardiovascular medicine, infectious diseases, infection prevention, pulmonary, critical care medicine, and pharmacy.

Several of the rooms on the inpatient COVID unit did not have windows that enabled staff to easily see the patient when the door was closed. Room cameras were enabled for several rooms that had them preinstalled, and baby monitor cameras were purchased for the other rooms so that all patients could be monitored visually from a central location. The facility also purchased thermometers and pulse oximeters. These were used to monitor all patients who tested positive for COVID-19 but were initially deemed not to require admission. Frequent video or telephone visits were conducted with all outpatients to ensure they did not subsequently require additional care. Several patients were identified to be deteriorating clinically and were referred for admission prior to severe deterioration. Scrubs were ordered for employees in patient care areas and laundered at the cost of VACT. Surgical masks were also provided to all health care workers. In order to ensure safe discharges for COVID-19-positive inpatients, Benjamin Cherry, MD, led a newly created hospitalist post-discharge video clinic to follow up discharged patients and assess their oxygenation and vital signs.

In recognition of the mental health aspect of receiving a new diagnosis of COVID-19, the Department of Medicine at VACHS worked with other mental health services and developed a process in which every inpatient with a mental health diagnosis would be visited by the psychiatry consult liaison service, and every other inpatient would be offered services by our health psychology team.

The volume of COVID-19 patients at VACHS was lower than that experienced at YNHH, but unfortunately, the hospital did lose nine patients to COVID-19. The oldest patient to pass away was over 100 years of age. He had fought in the Battle of the Bulge during World War II and had been a prisoner of war.

A Call for Volunteers

Based on other institutions’ experience in the United States and across the globe, leadership quickly recognized that the most severe challenge to patient care in the hospital would occur in the Internal Medicine wards; in particular, in the MICUs. Providing attending house staff and nursing coverage for the latter was anticipated to be the largest potential barrier to maintaining patient care of the highest quality. To meet this challenge, Tanoue collaborated with Yale Medicine (YM) leadership to poll the entire Yale School of Medicine (YSM) faculty electronically in order to identify physician faculty from other departments who would be willing to work on the Internal Medicine service, and who were capable of providing critical care or general medical care independently or with supervision. A remarkable outpouring of volunteers followed, with over 800 faculty members from every department at YSM responding to the survey.

Subsequent surveys identifying their own department responsibilities, restrictions to working with COVID patients, and a critical care skills analysis, resulted in a cohort of nearly 100 faculty who were deployed as needed in the ICUs and on the Medicine wards. Tanoue and Andrew Golus, MBA, associate director of strategic planning and population health for Yale Medicine, collaborated to categorize each volunteer. A separate team led by Shyoko Honiden, MD, MS, fellowship program director at PCCSM, and Margaret Pisani, MD, MPH, vice chief for faculty development and mentoring at PCCSM, did the physician scheduling and deployment with operations managers Helen Siuzdak and Jim Martone.

Every section within the Department of Medicine provided volunteers for the needs of the MICU; no one said no to Tanoue. General internal medicine, digestive diseases, cardiovascular medicine, and nephrology faculty, along with many others across the department, stepped in to work in the MICU for the months of April, May, and June. Fellows from the Sections of Endocrinology and Metabolism, Hematology, Medical Oncology, Nephrology, General Internal Medicine, Cardiovascular Medicine, and Geriatrics stepped back into the resident role to work as house staff. Pulmonary, Critical Care, and Sleep Medicine fellows functioned as attendings or fellows on critical care teams, led by Chief Fellow Mark Godfrey, MD.

Another request for volunteers was sent to residents and fellows of other departments to work within General Medicine units at YNHH. The request was coordinated by Inginia Genao, MD, and Stephen Huot, MD, PhD. The response was overwhelming. Over 177 residents and fellows from the Departments of Anesthesiology, Neurology, Dermatology, Pathology, Surgery, Radiology and Biomedical Imaging, Psychiatry, and Pediatrics volunteered to assist the Department of Internal Medicine with its patient load.

In addition, over 70 community physicians were issued emergency credentials to treat patients within the hospital. At VACHS, health care teams were restructured to provide longer resting periods between shifts so that staff members could de-stress. House staff was included. These changes were made to dispel fears, enhance preparedness, strengthen the workforce, and continue its dedication to education. In addition, protocols were created with a backup workforce and hospital space to be deployed for waves of anticipated COVID-19 surges. Select VACHS employees went on Disaster Emergency Medical Personnel System/FEMA/VISN deployments to Massachusetts, California, New Jersey, New York, Rhode Island, and New Haven, Connecticut.

Testing at VACHS began on March 10, 2020. Led by Brian Linde, MD, employee health testing was robust. Nasopharyngeal testing was performed for symptomatic clinicians, researchers, educators, and staff. Antibody testing was also offered on a regular basis to nurses and clinical staff. As of November 2020, over 7,000 people had been tested at VACHS. Outpatient testing was set up by Primary Care, led by Christopher Ruser, MD, and was a major success.

Evolution of Clinical Care

As the number of patients grew at YNHH, the teams adapted to changes in workflow and clinical care. High-risk clinically active faculty and trainees were asked to avoid being physically present on campus. To reduce disease spread, physicians were asked to keep traffic in and out of rooms to a minimum. Video capabilities were made available to communicate with patients with suspected or diagnosed COVID-19.

Infectious disease specialists Lydia Aoun-Barakat, MD; Erol Fikrig, MD; Manisha Juthani, MD; Merceditas Villanueva, MD; and Vincent Quagliarello, MD, led by Infectious Diseases Section Chief Erol Fikrig, MD, began consulting on every COVID-positive or COVID-excluded patient, either in person or through video conference to help preserve the use of additional PPE. They reconfigured numerous teams to meet the rapid increase in consulting requests, and added two additional COVID-specific teams to the York Street Campus (YSC).

Pulmonary, Critical Care and Sleep Medicine (Yale-PCCSM) Section Chief Naftali Kaminski, MD, and Jonathan Siner, MD, clinical chief, Yale-PCCSM, prioritized critical care as they announced to the section that their clinical mission was now of the utmost importance. They established a clinical command center, and reorganized the section to address the escalating needs of managing critically ill patients. All critical care board-certified physicians were deployed either as attendings; as supervisors to volunteer teams; as administrative leaders for system-wide critical care, physician deployment, respiratory care and supply chains; or with a backup team covering all needs. The outpatient services were converted to tele health by Jennifer Possick, MD, director of the Yale PCCSM outpatient services; and the tele-ICU services were expanded to address the increased needs of regional hospitals. Physicians considered to be at high risk for care of COVID patients were assigned to cover the outpatient telehealth lines and the tele-ICU. For patients who were in need of such urgent cardiac procedures, as cardiac catheterization and pacemaker or defibrillator implantation, YNHH leadership established protocols to limit the risk of COVID exposure for both patients and health care providers.

The department assembled a group of experts across many specialties to create a treatment guideline for patients diagnosed with the disease. Led by infectious disease physicians, the COVID-19 treatment team created a plan for moderate and severe disease for use across the Yale New Haven Health System (YNHHS). The first iteration was created on March 18. The plan was based on available knowledge, personal observations, and communications from other institutions. In the absence of firm evidence for best treatments, the treatment guidance was intended as a working document subject to revision with additional clinical research data.

The document was updated over time to include recommended medications and provide the rationale for their use; information on adverse reactions; and other considerations that emerged.

The department’s communications team started sharing the COVID-19 treatment guideline on Twitter (@YaleIMed) on April 1 with the hope of assisting others with patient care information. The response was tremendous. Requests for the protocols spanned several continents and dozens of countries—from Argentina to Zimbabwe—with a combined reach of nearly 150k with the first tweet of the protocol. The team consisted of experts from across many disciplines, including infectious diseases, pulmonary, critical care, sleep medicine, allergy and immunology, rheumatology, hematology, hospital pharmacy, and others. The treatment protocol has been incorporated into Epic workflow, adopted across YNHHS, and updated 20 times since its initial release. In addition to the treatment guideline, a variety of experts across the department created protocols and algorithms within their specialties:

• Due to the thrombotic complications seen in COVID-19-positive patients, hematologists were a critical part of the multi-disciplinary team. Alfred Lee, MD, PhD, Robert Bona, MD, Henry Rinder, MD, George Goshua, MD, and Lydia Tran, PharmD took the lead. Other faculty stepped up to consult and develop an anticoagulation algorithm.
• Systemic inflammation is an important complication of the virus, which causes respiratory compromise and death in susceptible patients. With the leadership of Section Chief Richard Bucala, MD, PhD, the Section of Rheumatology, Allergy and Immunology worked across interdisciplinary groups to advise on the assessment of inflammatory markers and design protocols for anti-inflammatory therapies.
• Patients with diabetes often presented with extremely high blood sugar levels that were hard to control. For those patients who received insulin infusions, nurses had to go into the room and check their blood sugar every hour, thus risking possible COVID exposure. Silvio Inzucchi, MD, and colleagues in endocrinology revised the insulin infusion guidelines and updated SBARs to maintain excellent patient care and conserve PPE. In addition, the endocrinology team added an automatic Epic alert for COVID-positive patients if their glucose rose to a certain level, and offered to consult on that patient.
• Geriatricians began consulting on the severe delirium seen in older patients caused by a combination of the virus’ effect on the brain and the isolation caused by the disease. These frail adults, particularly those from nursing homes, were likely to get very sick and require intensive care and/or a ventilator. The Section of Geriatrics studied the data coming out of Italy and China on this population.
• Medical Oncology and Hematology moved their ambulatory emergency center to the first floor of YCC. There they could do rapid COVID testing to protect their patients with compromised immune systems. Ambulatory care of patients continued with physicians and APPs quickly adjusting to telehealth visits. Such nursing leaders as Lisa Barbarotta, APRN, other practice nurses, and APPs continued to provide direct care to patients in the ambulatory space on a daily basis.
• Nephrology physicians performed a risk assessment based on the data coming out of China and Seattle on the rate of COVID patients developing acute kidney injury (AKI). The nephrologists determined that additional dialysis machines would be needed to care for the possible influx. The team worked with hospital personnel to obtain 15 additional continuous renal replacement therapy (CRRT) machines. Newer functionality of the CRRT machines meant easier monitoring by the nursing staff and less exposure to a COVID-positive patient. Luckily, many patients were managed using medical therapies and didn’t progress to needing dialysis.
• Thomas Prebet, MD, and Christopher Tormey, MD, led a group focused on the development of an algorithm organizing blood transfusion priorities. The status of blood product stocks was evaluated in real time and communicated daily to the Departments of Internal Medicine and Surgery.
• Sumeet Pawar, MD, a 2020 graduate of the cardiovascular medicine training program, developed an eConsult process with Daniel Price, MD, and helped to educate primary care providers about this process.
• Cardiovascular Medicine Fellow Kerrilynn Carney Hennessey, MD, developed a system to triage echocardiography requests during COVID-19 with Echo Lab director Lissa Sugeng, MD; Robert McNamara, MD, MHS; Kamil Faridi, MD, MSc; Vratika Agarwal, MD; and Aaron Soufer, MD.
• An Advanced Therapeutics group was established and led by Richard Bucala, MD, PhD; and Naftali Kaminski, MD. This group was in charge of assessing scientific evidence for promoting novel therapies, diagnostics, and scientific advances into patient care, and for advising the treatment guideline group.
• The pandemic created a new challenge for David Rosenthal, MD, who cares for homeless veterans. If someone had to be quarantined, how would that be possible if that patient didn’t have a home? The potential of infecting others was significantly higher. Rosenthal worked with City of New Haven staff and leaders to care for patients in a 50-bed shelter in the gymnasium of Hill Regional Career High School in New Haven. Rosenthal was assisted by physicians and nurses from Yale’s National Clinician Scholars Program and by other colleagues in the community.

In mid-March, when stories began circulating in the mass media about New York City hospitals and their limited resources, concerns about depletion of resources at Yale became an urgent challenge. Department physicians Michael Bennick, MD; Lauren Ferrante, MD, MHS; John Hughes, MD; Sarah Hull, MD, MBE; Jennifer Kapo, MD; Ernest Moritz, MD; and Mark Siegel, MD teamed with physicians, ethicists, and a lawyer within YSM and YNHHS to form the Ethics Advisory Workgroup and develop protocols to establish a fair and ethical process for the allocation of potentially limited resources. They drafted the Critical Care Triage Policy to save as many lives as possible in a setting of limited resources. The task force also formulated a resuscitation policy.

Concerns for a potential ventilator shortage during the surge required Elaine Fajardo, MD, director of Respiratory Therapy, to work together with hospital leadership to seek solutions to expand the availability of ventilators and even consider the use of ventilator splitters that allow the treatment of more than one patient. Two such possible solutions allowing the ventilation of two patients on one machine would be developed at Yale: the Vent Multiplexor and PReVentS. Both devices allow the ventilation of two patients using one machine while still individualizing the ventilation. Fortunately, these solutions were never needed.

As visitor restrictions were implemented across Yale New Haven Health and VACHS hospitals, ambulatory/outpatient sites, and clinics in mid-March, other workflow changes were made as department teams implemented creative solutions to assist with patient care. The Palliative Care service, led by Kapo and Laura Morrison, MD, partnered with Auguste Fortin VI, MD, MPH, and Geriatric-Palliative Care Fellow Rebecca Spear, DO, to create proactive COVID-19 communication support for a variety of scenarios to assist clinicians to have the necessary but challenging conversations with patients’ family members that could no longer happen in person. In response to the rapid increase in older adults with severe COVID-19 infections for whose prognosis was uncertain, geriatrics and palliative care specialists combined efforts to reach out to all patients 65 and older admitted to YNHH with COVID-19 and their families to have goals of care discussions and address their concerns.

The Grimes Center, YNHHS’ 120-bed skilled nursing facility, experienced a COVID outbreak among its residents and staff. Led by James Lai, MD, MHS, and Gerard Kerins, MD, the team of physicians, APRNs, and staff created new protocols to care for this vulnerable group of patients. They distributed these protocols nationwide to assist other skilled living facilities finding themselves in a similar situation.

PCCSM physicians Danielle Antin-Ozerkis, MD; Ashley Losier, MD; and Andrey Zinchuk, MD, were also struck by the communications complications associated with the disease. Updating family members became more difficult, as did decision-making conversations. The trio sought to obtain additional resources, specifically Apple iPads with video messaging capabilities to assist their patients and families. Concurrently, YNHHS IT team members Jennifer Travers, Glynn Stanton, Elliot Jimenez, and Katie Arcangelo; Tina Bennett in Patient Experience; and Leslie Hutchins in Nursing Informatics had been working on a similar project and were happy to partner with the team to speed up distribution of the devices. IT obtained, reimaged, and distributed the Family Zoom iPads across five COVID MICU units at YNHH’s York Street Campus and two COVID-designated areas at SRC.

In early April, collaboration between ITS and Pulmonary/Critical Care Medicine leadership resulted in a dramatic expansion of tele-ICU services across YNHHS, with 220 tele-equipped rooms available—up from 70 monitored beds before the pandemic began. The team also set up a daytime tele-ICU care program to support Westerly and Greenwich Hospitals during the day to assist in staffing shortages. In addition, large-volume infusion pumps were moved outside the ICU rooms to reduce the need to don PPE to make rapid changes to IV infusions.

Adjustments continued, punctuated by gestures of support. Generalist Firm Chief Gretchen Berland, MD, and her colleagues created a “PPE mudroom” where caregivers could put on and remove their PPE. They bought plastic containers to store their N-95 masks. One physician noticed a patient was afraid and isolated, so he started to play the patient’s favorite music. Another patient loved baked Cheetos, which a physician supplied. Care Coordination rounds were held over Zoom. Even day-to-day attire was changed to scrubs. Urgent efforts by SCH/YCC and the Section of Endocrinology launched a Smilow Endocrine Neoplasia weekly clinic to handle urgent outpatient consultations during the time when clinics were mostly shut down. Endocrinology also created a Yale Diabetes Center weekly clinic to handle urgent outpatient consultations. In mid-April, a Comfort Measures Only (CMO) unit was created on Verdi 5E, which provided for 91 patients who sought hospice care. Another supportive care unit was created in the outpatient clinic on NP-4, which fostered an atmosphere of compassion and focused care for patients who were not only dying but isolated and distanced from their loved ones due to the pandemic. The CMO unit was led by Elizabeth Prsic, MD.

As knowledge about the disease continued to accumulate, it became apparent that COVID-19 symptoms can linger for months after diagnosis. PCCSM physicians Denyse Lutchmansingh, MD, and Jennifer Possick, MD, established the Winchester Chest Clinic’s Post-COVID-19 Recovery Program. They continue to partner across YNHHS to care for patients with post-COVID complications. Moreover, cardiologists Nihar Desai, MD, MPH, and Tariq Ahmad, MD, MPH, added COVID-19 information to their Heart Failure Registry because these patients are at heightened risk of heart failure. The surge of inflammatory cytokines which the disease can cause may lead to myocardial damage and eventual heart failure. Under the leadership of Parul Gandhi, MD, the Congestive Heart Failure Transitional Care Clinic at VACHS adapted to the COVID-19 era by combining on-site clinical care with cardiology providers along with telehealth care for nutrition, health psychology, nursing, and pharmacy using both phone and video capabilities.

Rethinking Traditional Firm Structure

The internal medicine service at YNHH is organized into 12 firms by specialty. On a typical day, teams of one or two residents and one or two interns rotate with attending physicians caring for patients and performing bedside rounds. Each firm is headed by one or more firm chiefs.

Department leadership understood that physicians on the medicine firms would be in high demand and constrained. New rounding practices drawn up by Vincent Quagliarello, MD, Mark Siegel, MD, and Primary Care Residency Director John Moriarty, MD, were announced on March 23 in the teaching firms in order to minimize risk of exposure to patients and providers.

Moreover, on March 26, the department announced the restructuring of its firm system and the manner in which residents, faculty, and hospitalists are deployed. Led by Thomas Donohue, MD, and William Cushing, PA-C, the hospitalists (physicians who care for patients exclusively in the hospital) were spread across new units throughout the hospital.

Responsibilities of the pulmonary, critical care, and general internal medicine specialists were expanded to care for the influx of those needing care. Significant changes were also made to the units that treated nephrology, medical oncology, and digestive diseases patients.

On March 27, the Donaldson Firm and the Goodyear teaching services were moved to the hospitalist service. On the same day, pulmonary and critical care experts Astha Chichra, MBBS; Geoffrey Chupp, MD; Elaine Fajardo, MD; Shyoko Honiden, MD, MS; Melissa Knauert, MD, PhD; Margaret Pisani, MD, MPH; Mark Siegel, MD; Jonathan Siner, MD; Lynn Tanoue, MD, MBA; and Mayanka Tickoo, MD, became shift commanders for pulmonary and critical care in this new setting. Lydia Aoun-Barakat, MD; Marjorie Golden, MD; Manisha Juthani, MD; and Merceditas Villanueva, MD, led the teams for infectious diseases. In late March and early April, the Cooney, Fitkin, Medical Oncology, Hematology, Generalist, Peters and Klatskin Firms were moved. House staff were moved to other hospital locations. The Klatskin service continued to care for liver patients but at a lower capacity. The Verdi General Medicine service remained unchanged.

To assist clinicians new to providing care without residents or advanced practice providers, Resident Marla Jalbut, MD, MBA, and Departmental Electronic Health Records (EHR) Utilization Specialist Sinead McKernan created three instructional videos with practical directions for placing orders to admit a patient; to provide care during an admission; and to discharge a patient.

Transition to Virtual Visits

In mid-March, Yale Medicine clinic schedules were actively reduced across department practices in an effort to lessen traffic and potential disease spread. Patients were asked to be seen via remote visits by phone or video. All nonessential procedures were postponed.

Ilana Richman, MD; Joyce Oen-Hsiao, MD; and Sarah Mougalian, MD partnered with representatives from each section to rapidly implement the use of video telehealth. The trio partnered with McKernan to prepare support documents for video or telephone visits. By March 16, a majority of patient appointments were performed remotely either through phone calls or video visits. Routine visits were rescheduled for later dates.

For patients of Yale’s Dorothy Adler Geriatric Assessment Center, the conversion to virtual visits came with its own set of challenges. Caring for a patient population that might not be tech-savvy proved difficult. Richard Marottoli, MD, MPH; James Lai, MD, MHS; and Assistant Director of Geriatric Services, Kathleen Maturo, walked patients through the process using MyChart and other video tools. Leo Cooney Jr., MD; Mary Tinetti, MD; and Marottoli devised a way to perform cognitive testing by phone.

PCCSM transitioned all of the ambulatory services of the Winchester Chest Clinic (WCC) to telehealth. Because nearly all the physicians in the practice in WCC are critical care board-certified, they were needed in the expanded medical intensive care units. Jennifer Possick, MD, and Denyse Lutchmansingh, MD, redesigned their operations using mainly fellows and faculty considered too high-risk for face-to-face patient management. A team of medical student volunteers helped to arrange the patients in their virtual rooms. 3359 telehealth/ telephone visits occurred from March to June.

The Section of General Internal Medicine’s two primary care centers (PCCs) quickly shifted from primarily resident-based care as house staff were pulled from the clinics to care for COVID patients in the hospital. Under the leadership of medical directors Laura Whitman, MD, and Daniel Tobin, MD, MS, these practices, which care for over 10,000 patients, quickly moved to faculty-based care and telehealth with great success. Similarly, Yale Internal Medicine Associates (YIMA) redesigned its practice under the direction of Matthew Ellman, MD, who also developed a program to provide care for residents who contracted COVID-19 infection themselves. General internal medicine faculty included those from the PCC and Yale’s Physician Associate Program to create a new program to provide virtual care for patients infected with COVID-19 after they left the hospital to return home.

With a majority of its care given in the outpatient setting, patients of the Section of Rheumatology, Allergy and Immunology began to experience a shortage of hydroxychloroquine (HCQ), a critical medication used to treat lupus. Hydroxychloroquine helps lupus patients remain in remission. Richard Bucala, MD, PhD, made a direct and successful appeal to Teva Pharmaceuticals to obtain 10,000 tablets of the medication to provide to patients free of charge who couldn’t obtain the drug. Luckily, long before COVID-19 appeared, the VACHS already had systems in place to provide virtual visits by phone or videoconferencing. In fact, virtual care had been used for nearly a decade before COVID-19. Once the pandemic struck, the official switch to telemedicine was led by Christopher Ruser, MD. A website gave veterans access to pharmacy services, appointment scheduling, their personal medical records, and secure email messaging to their VA health care team. In addition to the website, VA Video Connect, a mobile application that gives patients the ability to schedule an at-home video health care visit with a primary care physician, was in use before the pandemic. Most telephone care before the pandemic was done using existing VA phone lines because no clinical providers were working from home at that time. VACHS clinical staff began online training with telemedicine about two years ago. By fiscal year 2019, all clinicians had been trained to use telephone, video, and secure email messaging, and had carried out at least one video visit with a patient.

In early March, all veterans were contacted about the use of mitigation strategies and COVID-19 precautions at the facility. When the federal government announced the national stay-at-home mandate, VACHS was already providing full virtual care to patients.

Nonessential visits and elective or non-emergent procedures were converted or cancelled altogether. More than 58,000 veterans utilized telemedicine during the pandemic.

The VA had a call center to triage calls about COVID-19 symptoms, medication refills, or other patient concerns. In mid-March, VACHS started a COVID-19 virtual triage clinic along with drive-up testing.

Communications

Gary V. Desir, MD; Lynn Tanoue, MD, MBA; and Aldo Peixoto, MD drafted and distributed the first of daily updates on March 11, which kept clinicians, researchers, educators, trainees, staff, and community physicians informed about critical changes to protocols and policies. This email would be the first of 43 messages sent by Desir to departments and leaders across YSM, YM, and YNHHS during the first wave of the pandemic. These 2,200 recipient email updates continued until June 26, 2020. These updates proved to be a valuable resource, highlighting key information about wellness, clinical care, research, education, and administration.

The department communications team, led by Julie Parry with the assistance of staff from the Section of Endocrinology and colleagues in the department’s business office, created a daily survey to monitor the health of its most valuable resources: its people. The survey consistently drew over 1100 responses, with its peak of 1391 on March 19. Reported illness also peaked on March 17, with 2.0% of those surveyed reporting symptoms. The wellness data compiled by Sean Stacy were shared in Desir’s daily messages.

This survey design was replicated by other departments and continued until mid-November, when it was rolled into Yale University’s process. Additionally, the communications team built a website to host updates and documentation, and partnered with the Clinical Affairs team led by Jennifer Lacerda to have the most current information available on the page.

Support for Caregivers

As the pandemic continued, additional support for those providing patient care was introduced in conjunction with other YSM departments and YNHHS. On the individual level, stress assessments, wellness checks, hotlines, counseling, quiet reset rooms, mindfulness-based stress reduction, and other programs were created. On a team level, the buddy system, peer support, and coaching were instituted along with team huddles. Town halls and mindfulness sessions were started on the community level. The department also started a peer-to-peer counseling program led by Jennifer Kapo, MD, and Robert Soufer, MD.

In addition, to assist those health care providers who were most affected by COVID-19 on the frontline, a food delivery initiative was started for house staff who stayed home in isolation as well as those who were displaced due to COVID-19. The effort was led by Claudia-Santi Fernandes, EdD, LPC, from General Internal Medicine. Over 1050 meals were given to health care workers sick with the disease. $35,000 was raised in support of this initiative.

Housing in local New Haven hotels was also provided for those physicians and residents who were in need of temporary accommodations due to high demand in high-risk areas, or were ordered to self-isolate but were unable to do so safely at home. Stephen Huot, MD, PhD, and Helen Siuzdak led this effort.

Health Disparities & Diversity, Equity, and Inclusion

Creative solutions were implemented to keep many existing diversity, equity, and inclusion initiatives moving ahead. Since travel was restricted, diversity committee members were unable to visit historically black colleges and universities for recruiting as in year’s past. Other opportunities to recruit at national conferences were also curtailed. To overcome these obstacles, Associate Chair Inginia Genao, MD, in collaboration with Minority Housestaff Organization, Diversity Council and others, organized a virtual information session for future URiM resident applicants, which had over 100 students in attendance across all graduate medical education programs. Program directors, faculty, and current residents joined the Zoom call to share their experiences and answer questions.

In addition, the team partnered with Quinnipiac University to recruit their undergraduate students to visit and learn more about the Yale School of Medicine. The launch of the New Haven pipeline project, to introduce medicine to younger audiences, has been delayed until March 2021.

Along with existing projects, Genao and her team sought to support the greater New Haven community and limit the spread of the virus. They organized a mask distribution to the community with the assistance of the Yale Center for Clinical Investigation (YCCI) Cultural Ambassadors, made possible by a donation from Masks for CT Organization; Mask Transit; and Richard Bucala, MD, PhD, John Wysolmerski, MD, and Naftali Kaminski, MD. To assist with further outreach in underserved communities, Genao; Charles Dela Cruz, MD, PhD; Marcella Nunez-Smith, MD, MHS; and others participated in a virtual Yale Cultural Ambassadors Town Hall on COVID-19, in conjunction with YCCI. These town halls were held weekly. In addition, a list of resources in numerous languages was created and distributed by Genao to department faculty to share with patients. Genao also coordinated other mask distributions to underserved New Haven communities.

The COVID-19 pandemic brought health disparities back to the forefront. Black and brown communities have endured a disproportionately high mortality rate because of this virus, and at the end of May, when George Floyd was killed, we were reminded of the deep-rooted racism in our country. Genao, along with her colleagues across the Section of General Internal Medicine, began hosting town halls to support the URiM faculty, residents, fellows, and trainees within the department. These open forums were a time to meet virtually and connect with others to share frustration and sadness. Genao and Gary V. Desir, MD, sent a message to the department to address these two epidemics. Department residents Sumit Kumar, MD, MPA; Nazeela Awan, MD; Asadullah Awan, MD; Jake Quinton, MD; Janani Raveendran, MD, MEd; Julia Rosenberg, MD; Hannah Rosenblum, MD; Rahul Shah, MD; along with Psychiatry’s Kiki Kennedy, MD, and Dentistry’s Lydia Hunt, DDS, MPH, arranged YSM participation in the New Haven Green march on Friday, June 5. The Department of Internal Medicine partnered with Yale New Haven Hospital to donate over 3,000 masks for the protestors. Nunez-Smith and others within the department highlighted health inequities in their in their research.

Genao partnered with Icahn School of Medicine student Aishwarya Raja to write about the challenges in underserved communities and lessons that can be learned from the pandemic in “Unmasking inequality: the power of community organization during COVID-19” on KevinMD.com.

Advocacy, Community Support and Outreach

In addition to efforts across YNHHS and VACHS facilities, clinicians, educators, researchers, and staff assembled in the community to slow the spread of the virus:

• In mid-March, due to the amount of misinformation regarding COVID-19 and inspired by a fellow section chief, Mary Tinetti, MD, partnered with Richard Marottoli, MD, MPH, to write, “Advice About COVID-19 For People Over 60 With Chronic Conditions,” which was published widely and provided to local governments, including the New Haven Mayor’s Office. The article discusses the outbreak; the steps that older adults and caregivers can take to stay healthy; and actions that local governments can take.
• A shortage of blood products occurred in early March 2020 that could have affected patient care. The Section of Hematology partnered with Lab Medicine and the Blood Bank to organize blood drives throughout March and April.
• Naftali Kaminski, MD, the immediate past president of the Association of Pulmonary, Critical Care and Sleep Medicine Division Chiefs, organized weekly meetings of all pulmonary and critical care division chiefs across the United States. In these Sunday night meetings, held before real evidence was available, they compared experiences, shared information and advice, and tried to establish best practices. These meetings were widely attended and reduced the burden of decision making during the early days of the pandemic’s spring surge.
• Recognizing that the lack of face coverings could contribute to the spread of the virus, the Community Health Care Van, a 40-foot mobile medical clinic created by Frederick Altice, MD, repurposed its activities starting on April 27. The van assists with combating the COVID-19 epidemic in vulnerable neighborhoods in the New Haven community. It is equipped with examination and counseling rooms and can communicate with Epic, YNHHS’s medical record system. The van’s mission is to support these neighborhoods by helping reduce community transmission through distribution of PPE and educational materials. In addition, the van provided postpartum visits for mothers and their infants, coordinated with telehealth visits with their doctor. Rather than using public transportation to travel to hospital clinics, mothers and infants could obtain care near their homes and reduce the risks to themselves and the rest of the community.
  • The van relies completely on outside support. Funding from YNHH’s Medical Staff Fund to provide community outreach jump-started the initiative with some assistance from the March of Dimes to supplement mother/newborn care. The YNHH Medical Staff Finance Committee, chaired by Lynn Tanoue, MD, MBA, was instrumental in obtaining funding to get the van back into the community, with a stipend that was matched by YNHH. A number of organizations, including the Yale School of Drama and The Shade Store®, donated face coverings to support the project. The program is directed by Sharon Joslin, APRN, FNP. Pediatrician Leslie Sude, MD, partnered with the department to offer newborn care. Outreach workers educated and provided PPE to the community, and mothers and newborn infants were scheduled for direct clinical care.
• With the guidance and support of COACH 4M and a faculty mentorship team that bridged Geriatrics and Geriatric Psychiatry, Yale medical students coordinated several volunteer activities to address challenges faced by older adults during the COVID-19 pandemic. These activities included virtual visitation with socially isolated older adults in local assisted living and skilled nursing facilities; partnership with a statewide volunteer network focused on grocery delivery for high-risk older adults; and helping patients and family members of our Northeast Medical Group geriatric home care program to sign up for and use MyChart.
• Second-year MD student Annika Belzer was on her clinical rotation when she learned all student rotations had to be put on hold for the next eight weeks because of the pandemic. She spoke with her preceptor, Peter Kahn, MD, MPH, about how students might offer indirect help with the COVID-19 situation. Those discussions quickly turned into the Yale Medical Student Task Force (MSTF). About 100 MD and MD/PhD students called patients who had their outpatient appointments cancelled or rescheduled as virtual visits due to COVID-19, to check on them and make sure they did not have any urgent medical or prescription needs. The students relayed the information to the patients’ providers, while on-call faculty members addressed any urgent needs. The first week involved a pilot project with endocrinology led by Silvio Inzucchi, MD. The students contacted about 600 patients over three days. The week of March 30 focused on cardiovascular medicine. The group rapidly created a structure that allowed many students to see results, with the help of Kahn, Inzucchi, Frank Bia, MD, and Peggy Bia, MD. The students received positive feedback from patients who, for example, were “really glad to know they have not been forgotten,” and from providers, for whom this extra support reduced their non-COVID workload.
• In early April, the New Haven County Medical Association leadership, current President Deborah Desir, MD, and Managing Director Jillian Wood, teamed up with students from the Frank H. Netter MD School of Medicine at Quinnipiac University to distribute N95 masks to all who requested them.
• In late April, the Yale Cancer Disparities Firewall (CDF) rallied to deliver face masks to local organizations to distribute to city residents. Medical Oncology Section Chief, Roy S. Herbst, MD, PhD, Ensign Professor of Medicine (Medical Oncology) collaborated with Kaminski, who donated the masks to the CDF for distribution. Included with the masks were fact sheets on the proper use and cleaning of cloth masks in both English and Spanish.
• Masks were also provided to support the march on the New Haven Green in June.
• Tapped to advise Connecticut Governor Ned Lamont on when and how to reopen the state were faculty from within the department, including Albert Ko, MD, Harlan Krumholz, MD, SM, Marcella Nunez-Smith, MD, MHS, and Carrie Redlich, MD, MPH. In May, the task force advised the governor on public health and economic recovery.
• Faculty across the department took to the airwaves, print, and web media to inform the public about the virus, instruct on ways to reduce spread; and discuss possible treatments, patient care, and other topics related to the pandemic. Department members were quoted in publications that included The New York Times, Good Morning America, CNN, Vanity Fair, Cosmopolitan, and 20/20. From January 1 to December 31, 2020, the department had 11,619* media mentions, with an ad equivalency of nearly $72.5M* *These figures do not include media mentions of Yale New Haven Hospital, Yale New Haven Health, or Smilow Cancer Hospital.
• On November 9, Marcella Nunez-Smith, MD, MHS, was named as co-chair of President-elect Joe Biden’s COVID-19 Transition Advisory Board. The full board, which includes 10 other physicians, scientists, and public health experts, will guide the incoming administration’s response to the COVID-19 crisis, including efforts to manage the surge of infections, ensure the approval of safe vaccines, and protect at-risk populations.
• Led by Luke Davis, MD, a group of 42 YSM clinicians, researchers, and educators sent an open letter to Connecticut Governor Ned Lamont on November 24, detailing the impact of the second COVID surge has had on frontline workers, and urging the governor to enact more restrictive measures to reduce the number of infections. In addition, an online petition garnered over 1,100 signatures. On December 1, Governor Lamont invited Luke Davis, MD; Gary V. Desir, MD; Manisha Juthani, MD; Naftali Kaminski, MD; Albert Ko, MD; Mark Siegel, MD; Jonathan Siner, MD; and Lynn Tanoue, MD, MBA, to meet to discuss workforce issues, surge capacity and potential actions that would decrease the spread of the virus. Also in attendance were Deidre Gifford, MD, MPH, Department of Public Health commissioner; Josh Geballe, chief operating officer; and Paul Mounds, chief of staff.
• In addition, Davis, Juthani, Kaminski, Ko, and others have expressed concerns and action steps to reduce viral spread via local, regional, and national media, including on such social media platforms as Twitter.

There were many more steps taken by clinicians, educators, researchers, and staff during the first wave of COVID-19. For more information, visit Internal Medicine.

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