Patient care is at the heart of any pandemic response. On May 1, in the third of a series of Dean’s Workshops on COVID-19, speakers discussed what School of Medicine Dean Nancy Brown, MD, called “the extraordinary preparations and both the individual and the team efforts that have enabled us to provide care across the region during a really unprecedented medical event.” The School of Medicine and Yale New Haven Health (YNHH) co-hosted the workshop. Previous workshops had addressed research and community responses.
YNHH is no stranger to short-lived mass casualty events, snowstorms, and even hurricanes. But, with the pandemic, “we knew going into this it was going to last many, many weeks,” said Thomas Balcezak, MD, YNHH’s executive vice president and chief clinical officer. He described the colossal logistical effort needed to prepare for and respond to the pandemic, involving everyone from call-center staff to childcare providers to cleaning crews to IT professionals.
By the time YNHH saw its first COVID-19 patient on March 8, its incident command structure had been in place for weeks, according to Michael Holmes, MSA, who is Yale New Haven Hospital’s incident commander. After that, change came quickly. The health system turned 26 of 80 inpatient units into all-COVID units and added 216 surge beds. It cut surgical volume by 85%, inpatient volumes by 16%, and emergency department visits by half.
“Not once can I tell you as incident command officer did I hear folks say, ‘No, we can’t.’ The response was, ‘How can we help you do this?’” Holmes recalled.
Nurses' versatility and bravery
Nurses stood at the forefront of these changes. Beth P. Beckman, DNSc, chief nursing executive of YNHH, outlined the rapid, transformative actions nursing staff took to protect themselves, provide high-quality care, and meet surging demand. To slow the personal protective equipment (PPE) “burn” rate, nurses reduced risky bedside visits by putting IV pumps outside patient rooms. Pediatric nurses found themselves providing comfort care to dying COVID-19 patients, while others rapidly trained in ventilator management and still more made the long round trip to staff overburdened Greenwich Hospital, the closest hospital in Connecticut to hard-hit New York City. Amid the unfamiliar deployments, many have thrived, bonding with one another across former silos, Beckman said. One major lesson, she concluded: the pandemic is a marathon, not a sprint—even if the initial response was sprintlike. “We had to make that adjustment, because we are in this for a much longer haul.”
Imaginative equipment sources
Before COVID-19, Lisa Lattanza, MD, chair and professor of orthopaedics and rehabilitation, had needed an N95 mask only about a dozen times in her 25-year career as an orthopedic surgeon. An ordinary surgical mask had usually sufficed. Lattanza took a leadership role in YNHH’s multipronged effort to ensure frontline workers had enough PPE. She worked with Yale engineers to develop 3D printed masks and set up a system for testing third-party masks to ensure safety for frontline providers. When Connecticut factories volunteered to make PPE, Lattanza worked with them to retool production lines that had formerly made furniture, parachutes, and even Halloween masks. She is far from the only Yale physician deeply involved in securing PPE. Patrick A. Kenney, MD, assistant professor of urology and vice chair of quality and safety in the Department of Urology, developed a method of sterilizing N95 masks with vaporized hydrogen peroxide; YNHH can treat up to 140,000 masks per week in this way. When Reinier van Tonder, MD, assistant professor of emergency medicine, had an idea to put a clear Plexiglas box over a patient’s head and torso during high-infection-risk procedures like intubations, Lattanza helped secure funding and connect him with nearby manufacturers. Within 10 days, the boxes were deployed across the hospital.
It remains unclear when the PPE supply chain will become more reliable, Lattanza said. Long-term preparedness may call for such innovations as non-disposable masks, increased production in the United States of N95s, and use of novel hospital air filtration systems, she said. “This is not a problem that is going to go away tomorrow.”
Algorithms for best practices
In the sea of pandemic uncertainty, a treatment algorithm may be a lifeboat for the frontliners. Maricar F. Malinis, MD, associate professor of medicine and surgery, co-founded the Yale School of Medicine/Yale-New Haven Health Treatment Group, with colleagues in the Section of Infectious Diseases. They began meeting in mid-March to develop COVID-19 treatment guidance for the health care system. Comprised of members from infectious diseases, pulmonary and critical care medicine, allergy/immunology, rheumatology, hematology, and antimicrobial stewardship teams, the group discusses potential therapeutic agents against SARS-coV-2 and other supportive therapies for hospitalized patients. They update the algorithm every week based on the most up-to-date literature and clinical data. “As infectious disease physicians, we have trained our entire careers for this moment,” Malinis said.
Accelerating research
As COVID-19 deaths mount, sound clinical research results are sorely needed. Yale has retooled its research infrastructure to launch COVID-19 studies more quickly, according to Eric Velazquez, MD, Robert W. Berliner Professor of Medicine (Cardiology). Beginning in mid-March, Yale centralized all COVID-related clinical research, appointing a single institutional review board (IRB) to review proposals in as little as five days. The board’s work is “heroic,” Velazquez said, with members often meeting daily and on weekends.
By April 28, the IRB had reviewed 201 studies, approving 99 new ones and modifying 61 existing studies. Investigators hail mostly from the School of Medicine but also from the schools of Law, Management, and Forestry & Environmental Studies, as well as the departments of economics, political science, and even linguistics. Changes to the electronic health record let patients enroll in multiple studies at once, the consent process has been streamlined, and study write-ups are publicly available even before peer review as “preprints” on the website. That “will put Yale in a very positive position to inform practice into the future with regard to COVID-19,” Velazquez said.
Analyzing the antibodies
When people recover from an infectious disease, their blood often contains antibodies that neutralize active virus. Those antibodies can be transferred in the form of “convalescent plasma” to people currently infected with the same germ. Though not risk-free, the treatment has been used for more than a century to treat infectious diseases, most recently SARS and Ebola.
Mahalia S. Desruisseaux, MD, associate professor of internal medicine (infectious diseases) and an expert in cerebral malaria, is spearheading an effort to study the treatment in COVID-19 patients. When a clinical team decides to give the treatment, it notifies Desruisseaux’s team, which follows the patient’s progress in hopes of learning about who is likeliest to benefit, ideal timing, and risk mitigation. Desruisseaux said that Yale patients have received the treatment, and best results have come when patients get the plasma earlier in the disease course. While they do not yet support the hope that antibodies confer immunity against reinfection, these findings suggest that convalescent plasma therapy does have clinical benefits.
One Yale physician got sick after a ski trip to Colorado. Another who had not traveled recalled a severe flulike illness in mid-February—weeks before Connecticut registered its first positive case. In a long-term study of more than a thousand Yale providers, they were among the few who tested positive for SARS-CoV-2 antibodies when enrollment began in early April. Carrie Redlich, MD, MPH, professor of medicine (occupational medicine) and of environmental health sciences, hopes the study will illuminate the rate at which health care workers “seroconvert” to test positive for these antibodies—and whether seroconversion protects them from reinfection. Doctors and nurses have flocked to enroll. “We became inundated with willing participants,” Redlich said. “Our medical students have been amazing and very busy.”
Transforming patient care
Leaders of COVID-19 clinical care teams are doing “unimaginably complex work in deeply uncertain times,” said Amy Wrzesniewski, PhD, the Michael H. Jordan Professor of Management at the Yale School of Management. She is working to understand how teams on COVID inpatient units and in the emergency department cope, adapt, struggle, or thrive. The COVID Clinical Leadership Support Committee, a joint effort of the schools of Medicine and of Management, offers direct support to team leaders while learning from them about best practices. Those include explaining the logic behind decisions, covering each other’s risky bedside tasks, ensuring that emotional-support staff reach out to overwhelmed caregivers, and keeping teams intact.
“We’ve been blown away by the levels of creativity, empathy, and proactivity that have been shown by the leaders of these units to solve problems and to foresee situations that just a few months ago would have been simply unimaginable,” Wrzesniewski said. These “silver linings” may point to a better future for patient care, she added: the pandemic “represents a critical opportunity for changing the status quo in otherwise inert systems.”
The past is gone
On April 21, the number of COVID-19 patients at YNHH peaked at 450 patients. To guard against a future surge, Balcezak said, the organization will need to increase testing up to 20-fold, institute widespread contact tracing, ensure adequate PPE, and restore the system’s depleted finances. Telehealth and telecommuting will continue, he said. “We will never go back to the way we previously operated as a business,” he said. “It’s up to us to figure out about what good things can come out of this.”
In concluding remarks, just two days after the health system celebrated its 1,500th patient discharge, Marna P. Borgstrom, MPH, CEO of Yale New Haven Health, said she was proud of the health system’s leaders. As we navigate the new normal, which may include periodic spikes in infections, Borgstrom said, “I think that we have a lot to be optimistic about—but we have a long way to go.”
Video of the workshop, and of the previous workshops, is available here.