The scientists and clinicians at Yale School of Medicine (YSM) and the Yale New Haven Health System (YNHHS) have performed herculean feats, and also faced daunting obstacles, as they work to tame the COVID-19 pandemic in Connecticut. That was the message from a panel of Yale experts who gathered on March 26 for “COVID-19 Update: Caring While Keeping Safe,” a virtual discussion sponsored by the Department of Internal Medicine’s Office of Global Health (OGH). Asghar Rastegar, MD, professor of medicine and director of OGH, moderated.
Yale’s work has included that of Marie-Louise Landry, MD, professor of laboratory medicine and of medicine (infectious diseases) and director of the Clinical Virology Laboratory. When tests for COVID-19 were lacking early in the pandemic, Landry and her lab developed one, meeting the exacting specifications set forth by the Food and Drug Administration (FDA), which the FDA needed to modify along the way as the pandemic grew and the need for testing became ever more urgent. In order to bring on a test quickly, Landry and the laboratory staff adapted the Centers for Disease Control and Prevention (CDC) test to the instruments available on site, established its accuracy, submitted their data to the FDA, and were able to fill an important need at YNHHS. “We tested inpatients suspected to have COVID-19, not only for Yale New Haven Hospital but for the other hospitals in the system,” Landry told the panel, “And we also provided testing to YNHHS health care workers, as well as community health care workers.” Landry noted that a significant obstacle to attaining the desired testing levels at Yale, as elsewhere, is the sporadic supply of reagents, the substances that laboratory tests use to actually identify the contents of patient samples. It was her hope that the supply chain would soon start delivering needed supplies more reliably.
Protecting health care workers has become paramount, both for their own welfare and for that of their families, the patients they treat, and the wider community. One aspect is deciding which patients really need to be in the hospital, where their risk of exposure to the virus may actually be higher, and who actually needs the hospital’s care, according to Andrew Ulrich, MD, professor and vice chair of operations in the Department of Emergency Medicine. “We’ve done a lot of work throughout the Yale Health system, and especially here in New Haven, of creating a space where we can quickly see, triage, and hopefully discharge back to home, patients who are less severe,” he explained, “and not bring them into the building where it really doesn’t benefit anybody.” YNHHS is also getting the word out to potential patients about not even coming in if possible. “There has been a lot of great work throughout the health system of trying to help patients appreciate and understand it’s best if they’re not in the health care system if they don’t need to be.” Maintaining a sufficient workforce is also essential, he added. “If we start to have the attrition that I’ve seen in New York and in other places, we’re really going to struggle with being able to staff and care for all the patients we are going to see.”
Parts of the health system itself have seen a physical transformation. Richard A. Martinello, MD, associate professor of medicine (infectious diseases) and of pediatrics, and medical director, infection prevention, for YNHHS, described “engineering controls” designed to limit the spread of the virus. “In the hospital we primarily use negative pressure rooms. For pathogens that are transmitted in an airborne manner, the negative pressure room really helps us to contain the pathogen to that area.” Many of those rooms were converted to be negative pressure by YNHHS Facility engineers in direct response to the COVID-19 pandemic. Martinello also described a constant need for more personal protective equipment for health providers, a problem plaguing medical facilities across the country. Ingenuity may be part of the solution. “We are trying to develop pathways for recycling some of the personal protective equipment that we would routinely just throw away,” he said, “while also looking to identify new sources and manufacturers for PPE. We also are trying to think about how we most efficiently use the personal protective equipment that we have available to us.”
Other aspects of protecting frontline health care workers have included their monitoring their own health, according to Mark Russi, MD, MPH, professor of medicine (occupational medicine) and of epidemiology (environmental health), and the health system’s director of occupational health services. “We have, essentially, a self-monitoring program of twice-daily fever checks, checks of symptoms, a check immediately before leaving home for work, and then remaining at home and calling in to get properly triaged and, where appropriate, tested.”
I think that we are ahead of many places right now, but unfortunately I am sure we will see more patients in the coming weeks.
Asghar Rastegar, MD
Intensive care units are another point of great concern nationwide, including Connecticut. Charles Dela Cruz, MD, PhD, associate professor of medicine (pulmonary, critical care, and sleep medicine) and of microbial pathogenesis, said the Yale system has developed procedures for determining who needs intensive treatment. “There’s a mechanism to figure out who gets transferred to the ICU,” he explained. “These are these patients who require increasing oxygen, like three liters of oxygen and increasing, as we have been trying to catch them early. The transfer indication is impending, worsening oxygen requirement, ventilator support, and other [standard] intensive care criteria that are non-COVID related.” There also is the need, as always, to treat patients with other conditions that are more typically seen in the ICU.
Yale is also working diligently on tracking transmission of COVID-19, the better to try to stop it in its tracks. Saad B. Omer, MBBS, MPH, PhD, director of the Yale Institute for Global Health, said most current risk in Connecticut comes from domestic sources. “We sit geographically between two major urban centers with pretty substantial outbreaks,” he explained. “A lot of people pay attention to New York because it’s a larger city,” Omer noted, “but Boston is also a major center with substantial outbreak going on.” Omer said the ultimate goal is a safe and effective vaccine for the novel coronavirus, something that will take time.
In sum, Rastegar, the moderator, called the pandemic “a very fluid situation” and said that “things are changing day by day.” He concluded, “I think that we are ahead of many places right now, but unfortunately I am sure we will see more patients in the coming weeks. So, there will be new challenges.”