Latest / The SHEA Podcast / COVID-19: Lessons Learned From The Surge, 7/02

Transcript

COVID-19: Lessons Learned From The Surge, 7/02 · The SHEA Podcast

• 0:08
  SPEAKER_03: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare-associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:22
  SPEAKER_03: I am Dr.
• 0:23
  SPEAKER_03: David Bannock from the University of Connecticut, and I will serve as today's podcast moderator.
• 0:27
  SPEAKER_03: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:36
  SPEAKER_03: Shay is excited to launch the 20th episode of this podcast, COVID-19 updates, What We Know Now.
• 0:42
  SPEAKER_03: Today's episode will focus on lessons learned from the COVID-19 surge.
• 0:46
  SPEAKER_03: Our speakers today are Dr.
• 0:48
  SPEAKER_03: Jennifer Hammerhan, infectious disease specialist at the University of Toledo, Dr.
• 0:52
  SPEAKER_03: Ainu Milani, infectious disease specialist at St.
• 0:55
  SPEAKER_03: Joseph Mercy Health System, and Dr.
• 0:57
  SPEAKER_03: Sharon Wright, infectious disease specialist at Beth Israel Deaconist Medical Center.
• 1:02
  SPEAKER_03: Thank you for joining us today.
• 1:03
  SPEAKER_03: I would like to turn it over to Dr.
• 1:04
  SPEAKER_03: Hammerhan to get us started with a brief news and guidance update from the week.
• 1:08
  SPEAKER_00: As of today, July 1st, 2020, there are 10,498,090 cases in the world of coronavirus.
• 1:18
  SPEAKER_00: There are 511,851 deaths to date.
• 1:22
  SPEAKER_00: This week, Dr.
• 1:23
  SPEAKER_00: Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, told the Senate committee that he would not be surprised if the daily count of new COVID-19 cases in the U.S.
• 1:33
  SPEAKER_00: reached 100,000.
• 1:35
  SPEAKER_00: Currently, over 40,000 people are being diagnosed every day.
• 1:38
  SPEAKER_00: As we hear about rising case numbers in many U.S.
• 1:41
  SPEAKER_00: states, the CDC has issued updated guidance on strategies for optimizing the supply of face masks.
• 1:47
  SPEAKER_00: This is a framework to approach a decreased supply of face masks during the COVID-19 response.
• 1:52
  SPEAKER_00: Three general strata have been used to describe surge capacity and can be used to prioritize measures to conserve face mask supplies.
• 1:59
  SPEAKER_00: The first is conventional capacity, and these measures consist of providing patient care without any change in daily contemporary practices.
• 2:08
  SPEAKER_00: This set of measures consists of engineering, administrative, and personal protective equipment controls that should already be implemented in general infection prevention and control plans in healthcare settings.
• 2:19
  SPEAKER_00: Contingency capacity is the next level, and these measures may change daily standard practices, but may not have any significant impact on the care delivered to the patient or the safety of healthcare personnel.
• 2:30
  SPEAKER_00: These practices may be used temporarily during periods of expected face mask shortages.
• 2:34
  SPEAKER_00: During contingency capacity, elective and non-urgent procedures and appointments for which a face mask is typically used by healthcare providers would be selectively canceled.
• 2:44
  SPEAKER_00: And then there's crisis capacity.
• 2:46
  SPEAKER_00: And in this stage, strategies that are not commensurate with U.S.
• 2:49
  SPEAKER_00: standards of care are implemented.
• 2:51
  SPEAKER_00: These measures or a combination of these measures may need to be considered during periods of known face mask shortages.
• 2:57
  SPEAKER_00: During crisis capacity states, all elective and non-urgent procedures and appointments for which a face mask is typically used by a healthcare provider would be canceled, and face masks would be used beyond the manufactured designated shelf life during patient care activities.
• 3:11
  SPEAKER_00: As an editorial note, none of these states describe the situation many hospitals in the U.S.
• 3:17
  SPEAKER_00: currently face, which is one in which there are enough face masks, but that is due to using them for longer periods of time than usual, coupled with the knowledge that shortages will exist again in the future.
• 3:28
  SPEAKER_00: Shouldn't preservation strategies for resources be put in place when there are enough supplies?
• 3:34
  SPEAKER_00: The MMWR published a report on June 30th titled Characteristics of Adult Outpatients and Inpatients with COVID-19, 11 Academic Medical Centers United States, March through May 2020.
• 3:45
  SPEAKER_00: During April 15th to May 24th, telephone interviews were conducted with a random sample of adults age 18 or older who had positive PCR test results for SARS-CoV-2 in outpatient and inpatient settings at 11 U.S.
• 3:58
  SPEAKER_00: academic medical centers in nine states.
• 4:00
  SPEAKER_00: Respondents were contacted 14 to 21 days after SARS-CoV-2 testing and asked about their demographic characteristics, underlying chronic conditions, and symptoms experienced on the date of testing.
• 4:11
  SPEAKER_00: Among 350 interviewed patients, 77% outpatients and 23% inpatients, inpatients were older, more likely to be Hispanic, and report dyspnea than outpatients.
• 4:22
  SPEAKER_00: Fewer inpatients reported a return to a baseline level of health at 14 to 21 days than did outpatients.
• 4:28
  SPEAKER_00: Overall, approximately one half of patients reported known close contact with someone with COVID-19 during the preceding two weeks.
• 4:35
  SPEAKER_00: This was most commonly a family member or a work colleague.
• 4:38
  SPEAKER_00: Approximately two-thirds of participants were employed.
• 4:41
  SPEAKER_00: Only 35 of 209 were able to tell a word.
• 4:44
  SPEAKER_00: These findings highlight the need for screening, case investigation, contact tracing, and isolation of infected persons to control transmission of SARS-CoV-2 infection during periods of community transmission.
• 4:56
  SPEAKER_00: Two articles were published in the New England Journal of Medicine on multi-system inflammatory syndrome in children.
• 5:02
  SPEAKER_00: The first one reported on 186 patients with multi-system inflammatory syndrome disease in children in 26 states.
• 5:09
  SPEAKER_00: The median age was 8.3 years, 62% were male, 73% had previously been healthy, 70% were positive for SARS-CoV-2 by PCR or antibody testing.
• 5:20
  SPEAKER_00: And organ system involvement included the GI tract in 92%, cardiovascular system and 80%, hemologic in 76%, mucutaneous and 74%, and respirator tract in 70%.
• 5:32
  SPEAKER_00: Median duration of hospitalization was seven days.
• 5:35
  SPEAKER_00: 80% received intensive care, 20% received mechanical ventilation, 48% received vasoactive support, and four patients died.
• 5:45
  SPEAKER_00: Another article on the same entity from cases in New York included 191 potential cases and demonstrated similar clinical findings.
• 5:56
  SPEAKER_00: The IDSA updated its guidelines for treatment of COVID-19.
• 6:00
  SPEAKER_00: Among hospitalized patients with severe COVID-19, the IDSA guideline panel suggests glucocorticoids rather than no glucocorticoids.
• 6:07
  SPEAKER_00: This is a conditional recommendation with moderate certainty of evidence and recommends dexamethasone, six milligrams IV or PO for 10 days, or until discharge if early, or an equivalent alternative glucocorticoid if dexamethasone is unavailable.
• 6:23
  SPEAKER_00: They do not recommend corticosteroids for patients who do not have hypoxemia.
• 6:29
  SPEAKER_00: Those are the updates for the last week in June 2020.
• 6:32
  SPEAKER_03: Thank you very much, Dr.
• 6:33
  SPEAKER_03: Hammerhan.
• 6:34
  SPEAKER_03: I now want to move into the discussion with Dr.
• 6:36
  SPEAKER_03: Malani and Dr.
• 6:37
  SPEAKER_03: Wright.
• 6:38
  SPEAKER_03: So, Dr.
• 6:38
  SPEAKER_03: Malani and Dr.
• 6:39
  SPEAKER_03: Wright, thank you both for joining the podcast this week.
• 6:42
  SPEAKER_03: You both experienced a surge in the early stages of the pandemic, Dr.
• 6:45
  SPEAKER_03: Malani in Michigan, and Dr.
• 6:47
  SPEAKER_03: Wright in the Boston area.
• 6:48
  SPEAKER_03: So I wanted to get into some of the details of your experiences as the pandemic evolved in your respective locations.
• 6:55
  SPEAKER_03: So first I'll turn to Dr.
• 6:57
  SPEAKER_03: Wright.
• 6:58
  SPEAKER_03: Can you share at least your overview of how things evolved going back to when you first had your cases at Beth Israel Deaconess and then what the subsequent months looked like during the pandemic?
• 7:08
  SPEAKER_02: So I think like most people, we were following the pandemic approaching and started having meetings several times a week in early January.
• 7:18
  SPEAKER_02: In the middle of the month, I think we sent out our first all-staff email to the hospital, and pretty quickly things escalated.
• 7:26
  SPEAKER_02: Just to give you a sense of the magnitude of what we experienced at our hospital, we normally have about 815 licensed beds.
• 7:35
  SPEAKER_02: And at the peak, which was around April 21st, we had 214 COVID-positive patients plus an additional 55 COVID suspect patients for a total of 269 patients who were on isolation.
• 7:49
  SPEAKER_02: Of note, we have 63% double beds in our institution.
• 7:54
  SPEAKER_02: So we had to block a number of beds in order to have enough private rooms, even though we were cohorting patients with confirmed COVID.
• 8:00
  SPEAKER_02: Additionally, we normally have 77 adult ICU beds, but far exceeded this footprint and ran approximately 102 beds daily during the week of the peak surge.
• 8:10
  SPEAKER_02: So the surge was something we've never experienced before.
• 8:14
  SPEAKER_02: And although it initially started gradually, we had to pretty quickly become nimble in flipping regular med surge units into ICUs and PACUs into med surge units.
• 8:26
  SPEAKER_02: And then when there would be fluctuations, we would flip back and forth depending on what we needed on a particular day or week.
• 8:34
  SPEAKER_02: So it was a constantly changing landscape that required a lot of flexibility from our infection control team and also for the entire medical center.
• 8:43
  SPEAKER_03: Yeah, we had a similar experience where basically our number of beds needed to rapidly escalate, and we sort of evolved the overall structure of our hospital in terms of expanding ICU capacity and then changing the focus of different units within the hospital in order to take care of the patients with COVID.
• 9:01
  SPEAKER_03: So, Dr.
• 9:02
  SPEAKER_03: Milani, can you kind of reflect a little bit on how your hospitals evolved throughout the pandemic?
• 9:07
  SPEAKER_01: Our first case was in early March.
• 9:10
  SPEAKER_01: This is actually a returning traveler from Egypt who had been on a cruise in the Nile River and she presented atypically.
• 9:18
  SPEAKER_01: She had severe diarrhea, evidence of colitis, leukocytosis, and several days into admission eventually developed respiratory symptoms.
• 9:26
  SPEAKER_01: For the next several weeks, including much of March, April, and early May, we had significant activity.
• 9:33
  SPEAKER_01: For a long period of time, Michigan only lagged behind New York and New Jersey in the number of cases.
• 9:39
  SPEAKER_01: At our peak, at the main hospital that I care for patients in Ann Arbor, we had over 130 confirmed patients, many more PUIs, and we hit our peak in the second week in April.
• 9:53
  SPEAKER_01: For much of that, kind of late March into early May, we had over 100 confirmed patients.
• 10:00
  SPEAKER_01: And about a quarter of them required ICU care, with about 20% of them requiring ventilation.
• 10:06
  SPEAKER_01: Our typical census is around 450.
• 10:10
  SPEAKER_01: We have a bed size of around 550.
• 10:12
  SPEAKER_01: And during this time, our census was obviously a bit lower with the complete slowing of elective and surgical and procedure cases.
• 10:20
  SPEAKER_01: And so we hovered around a capacity of around 300, with probably a third to almost 50% of our volume requiring COVID care.
• 10:29
  SPEAKER_03: Interesting.
• 10:30
  SPEAKER_03: So it sounds like quite a substantial evolution throughout the process.
• 10:33
  SPEAKER_03: So with that background of how things evolved within your hospitals, and I was hoping that you could reflect on your experiences over the past six months on how your professional role has evolved concurring with the progression through the first stages of the pandemic.
• 10:48
  SPEAKER_02: It's definitely been an interesting experience and not like one that I think I've experienced in my career so far.
• 10:55
  SPEAKER_02: You know, having lived through H1N1 and SARS, MERS, this was completely different because the pace and the volume was incrementally higher.
• 11:06
  SPEAKER_02: And so even though infection prevention and infectious disease often play a key role in infectious emergencies, there was just almost no way to physically keep up.
• 11:17
  SPEAKER_02: And so the relationships that we normally build in situations like this were even more important.
• 11:23
  SPEAKER_02: And in fact, a reliance on an incident command structure was critical because the work really had to be divided up and subgroups created for things like testing or PPE or operations.
• 11:35
  SPEAKER_02: And so it was difficult to kind of keep your finger on everything at the same time developing guidance for infection prevention, especially as we were dealing with a lot more unknowns than we sometimes do.
• 11:48
  SPEAKER_02: And so trying to take in often conflicting guidance in an evidence-free zone and make decisions for your institution in a way that you felt like you were keeping provider safe and managing anxiety was a little bit different than other similar situations of infectious emergencies that I've dealt with in the past.
• 12:28
  SPEAKER_03: Dr.
• 12:29
  SPEAKER_03: Malani, any other thoughts on how your professional role has evolved throughout the last six months?
• 12:34
  SPEAKER_01: Yep.
• 12:34
  SPEAKER_01: So my setting is a community teaching hospital.
• 12:37
  SPEAKER_01: And so I lead both infection prevention and microbial stewardship at multiple hospitals.
• 12:43
  SPEAKER_01: So on any given day, I wear you know many different hats.
• 12:46
  SPEAKER_01: And normal day-to-day activity can be very challenging.
• 12:49
  SPEAKER_01: And then I should also preface this that we actually went live with Epic.
• 12:54
  SPEAKER_01: We switched from Cerner to Epic at the end of January.
• 12:58
  SPEAKER_01: And a rollout, I'm a part of a much larger health system called Trinity Health, where we have 90 hospitals and we have seven hospitals in Michigan in the same system.
• 13:07
  SPEAKER_01: And so we actually rolled out Epic at the end of January.
• 13:10
  SPEAKER_01: And another personal challenge is that my previous director of infection prevention actually relocated to the Baltimore area in June of 2019.
• 13:20
  SPEAKER_01: And so I actually didn't have a director till the end of February, right?
• 13:24
  SPEAKER_01: Sort of when we were getting going with COVID.
• 13:27
  SPEAKER_01: I've been involved with several outbreak investigations and response, including being at the epicenter of the fungal meningitis outbreak back in 2012 and 2013.
• 13:37
  SPEAKER_01: But this really is an unprecedented time in the world, which really most of us have never experienced something similar.
• 13:43
  SPEAKER_01: It's been one of the most challenging times in my professional career.
• 14:06
  SPEAKER_01: Much of my time has been spent in coordinating and helping lead direct response.
• 14:11
  SPEAKER_01: So serving as ID, infectious diseases, IP content expertise, and liaisoning with many disciplines, you know, our C-suite locally, our incident command structure for the state.
• 14:23
  SPEAKER_01: So our chief clinical officer and our leadership for our state, and then our larger NAD hospital health system.
• 14:29
  SPEAKER_01: So a lot of different types of incident commands, locally, state, and then larger sort of system meetings, and then thinking about liaisoning with many different areas, laboratory and testing, you know, supply chain, personal protective equipment, IT and epic order sets, pharmacy, you know, media and communications with regular town halls, thinking about clinical care with our infectious diseases group, as well as liaisoning between emergency room and hospitalist care, thinking about as we sort of began to open up pre-surgical, pre-procedure testing and liaisoning between them and of course, you know, liaisoning between public health.
• 15:08
  SPEAKER_01: I think one thing about COVID that we all can agree upon is that really, as Dr.
• 15:14
  SPEAKER_01: Wright was mentioning, the pace of how quickly things were changing.
• 15:19
  SPEAKER_01: And from week to week, there were many different issues.
• 15:21
  SPEAKER_01: You know, early on, it was how do we get testing?
• 15:24
  SPEAKER_01: There was limited testing.
• 15:25
  SPEAKER_01: We had to unfortunately steward tests and really test the most critically ill.
• 15:30
  SPEAKER_01: And then results took upwards of a week initially, and then figuring out how we met test capacity with supplies, swabs, different types of tests, and different availability at different hospitals.
• 15:45
  SPEAKER_01: You know, PPE, having enough N95s, and then gowns, and then who should wear N95s and policies around reuse, extended use, reprocessing, trying to remove PUI as quickly as possible out of isolation, realizing and understanding the testing limitations.
• 16:01
  SPEAKER_01: On a personal level, my group of eight other ID physicians were very helpful in thinking about PPE and testing stewardship.
• 16:11
  SPEAKER_01: And for a long time, up until we really hit critical surge capacity, we, the infectious diseases group, saw all patients with COVID.
• 16:21
  SPEAKER_01: And I think that this was very helpful in terms of thinking about both PPE stewardship, testing, uh, antibiotic stewardship, but eventually became very difficult to do when we had such a high volume of patients.
• 16:35
  SPEAKER_03: Yeah, I think those are some really interesting points.
• 16:37
  SPEAKER_03: You know, certainly both of you mentioned the role of collaborating and building relationships with uh different groups throughout the entire facility is so critical.
• 16:47
  SPEAKER_03: We can't do everything ourselves, but uh, when we all work together, I think we see that collaboration provides that foundation for responding to these kinds of situations.
• 16:56
  SPEAKER_03: And the supply chain issues have been so critical for infectious disease.
• 17:02
  SPEAKER_03: We have a natural inclination to be stewards of antibiotics.
• 17:06
  SPEAKER_03: I think a lot of approach has been part of the portfolio stewards of testing when it was only available on a limited basis, and even medication.
• 17:17
  SPEAKER_03: So with drugs like endoscopy, even congles and plasma, you had to take kind of stewardship for how to optimize our use of those therapeutics.
• 17:28
  SPEAKER_03: I think it's all putting infectious disease and infection prevention in the forefront.
• 17:33
  SPEAKER_03: Dr.
• 17:33
  SPEAKER_03: Juan, you did mention um antibiotic stewardship, and I think that's an area that has gotten some attention throughout the COVID-19 pandemic.
• 17:42
  SPEAKER_03: Can you share some of your personal experiences in your antibiotic stewardship role?
• 17:46
  SPEAKER_01: Sure.
• 17:46
  SPEAKER_01: Yeah, I think we're fortunate to have a robust antibiotic stewardship program.
• 17:51
  SPEAKER_01: I think you know, we really tried not to deviate from our core principles, trying to have and follow as much as we can with COVID, you know, well-established evidence-based treatment guidelines with really an emphasis on diagnostic stewardship and antibiotic duration.
• 18:08
  SPEAKER_01: You know, I think initially this was a bit difficult.
• 18:10
  SPEAKER_01: We talked about some of the limitations around testing and timeliness of testing and who we could test.
• 18:16
  SPEAKER_01: And the reality was early on, when we didn't have a lot of experience with COVID, you know, many patients that were presenting with COVID could actually present similarly to patients with bacterial pneumonia.
• 18:28
  SPEAKER_01: And so I think that this evolved much like everything else, thinking about how we developed guidelines, particularly around treatment.
• 18:38
  SPEAKER_01: There was an abundance of evolving literature.
• 18:42
  SPEAKER_01: Again, you know, this was so fluid, so rapid, and trying to disseminate this information.
• 18:47
  SPEAKER_01: So we, as much as we could, we tried to use a multidisciplinary approach, really, with engagement and buy-in from all the ID docs, our pharmacists, our critical care and hospitals representation.
• 19:02
  SPEAKER_01: You know, initially, much like everyone else, we used hydroxychloroquine for all patients.
• 19:08
  SPEAKER_01: And, you know, really there was nothing else available.
• 19:10
  SPEAKER_01: But uh very early on, we kind of backed off on use.
• 19:14
  SPEAKER_01: And fortunately, you know, we were able to become a site for an expanded access trial for REMdesivir.
• 19:22
  SPEAKER_01: And I think this, along with participating in some trial work around convalescent plasma, also became part of stewardship as well as sort of ID care, is figuring out who could potentially benefit from trial access and thinking about monitoring these patients.
• 19:40
  SPEAKER_01: I think the other thing that we employed was the concept of handshake stewardship.
• 19:46
  SPEAKER_01: I think early on we tried to see every patient with COVID.
• 19:50
  SPEAKER_01: And even though we added a fourth rounding service, so we had four services at any time, we had all hands-on-deck approach.
• 19:58
  SPEAKER_01: Given the slowdown in surgeries, we had some of the advanced practice professionals from surgeries, we had PAs from our neurosurgery and orthopedic spine surgery helping us out for a couple of months, along with family practice residents rotating through ID.
• 20:13
  SPEAKER_01: You know, we had increased ability to see patients, but given the volume of patients, it was difficult to see every patient.
• 20:20
  SPEAKER_01: So what we typically did is the ID services would round and get together with the caring teams, uh, the different hospitalists and critical care teams on the COVID floors.
• 20:32
  SPEAKER_01: And you know, initially we started off on just one floor, but probably similar to Dr.
• 20:38
  SPEAKER_01: Wright's experience, you know, we clearly had to expand given the volume of patients.
• 20:42
  SPEAKER_01: But what we would typically do is we would try to go there at one point in time in the morning at the different floors, and it would be different docs depending on who was on, but discussing all the patients and thinking about which patients really would benefit from being seen by ID.
• 20:58
  SPEAKER_01: Now, as the volume has actually become a little bit lower in terms of the last month or so, we're back to back to now seeing every patient of COVID from an ID standpoint.
• 21:09
  SPEAKER_01: I think also understanding sort of the pharmacist role, shout out to our pharmacists who developed a sort of standardized care bundle around COVID and sort of for tracking their interventions.
• 21:21
  SPEAKER_01: And a couple things that they were able to do that I think was really very helpful in terms of thinking about PPUs and limiting healthcare worker interactions with COVID patients was trying to streamline optimization of medication therapy, thinking about workflow efficiency and how often nurses and providers needed to go into the room and consolidating those items for care.
• 21:43
  SPEAKER_01: I think the pandemic and sort of everything around the pandemic, with all hands on deck, really is a great opportunity to think about how stewardship and healthcare epidemiology and infection prevention work together.
• 21:57
  SPEAKER_01: I think, you know, definitely a time where the Programs really, if they don't have close relationships, a time where really close relationships can be fostered.
• 22:07
  SPEAKER_03: That's great.
• 22:08
  SPEAKER_03: I think there's a lot of great points that you just mentioned that we can be thinking about as we proceed through this.
• 22:13
  SPEAKER_03: So you know, both of you have had the experience at being in real epicenters of COVID-19, and now we're looking at other parts of the country that are surging in some areas that are surging quite rapidly and may be at the point where you both were, at least over the last few months.
• 22:31
  SPEAKER_03: So thinking back to your experiences, I'm interested to hear if you have any lessons that particularly stand out or any advice you would give to healthcare epidemiologists that are in these areas where they're starting to see surging.
• 22:44
  SPEAKER_02: I think that hopefully they've had the advantage of having a little more time to see what's been happening to those areas that were hit with the surge first, and time to think a little bit more about what makes sense, especially for PPE, and to start to build up a supply.
• 23:01
  SPEAKER_02: I think one of the most interesting lessons that we learned is that even with PPE, we have to be incredibly nimble, that we need to make sure that we have enough staff.
• 23:11
  SPEAKER_02: This was looking across a system who are all fit tested, who might not have needed to be in previous situations, and to think about the best way to use PPE and how to explain to staff that they're safe, and to have a bigger repertoire of different types of N95s in particular, so not relying just on one brand and to build some redundancy to be able to handle some of the instability in the supply chain.
• 23:41
  SPEAKER_02: And that would include things that we might not have considered before, such as non-medical N95s, reusable N95s, elastomeric respirators, and to think about ways if you are fortunate enough to be in a system that you can depend on each other, whether that's creating a transfer center.
• 23:59
  SPEAKER_02: You know, I am part of a system that was just approaching its one-year anniversary at the time that COVID hit.
• 24:06
  SPEAKER_02: And it did pull us together, but we didn't have a lot of shared systems.
• 24:11
  SPEAKER_02: And so it really meant that we had to meet some people for the first time and not know the structure of what some of the other sites look like, not have a similar computer system, not have a shared supply chain, and yet be willing to trust and share with each other.
• 24:25
  SPEAKER_02: And I think that worked really well.
• 24:27
  SPEAKER_02: And I think the other thing I would recommend is starting to think a little bit about trade-offs because I felt like, and still to this day, that we are continually trading off, often due to limited resources.
• 24:39
  SPEAKER_02: So at first there were a lot of limits with testing, whether that was media or swab kits.
• 24:45
  SPEAKER_02: We built basically a swab kit creation factory to make our own, but until we had enough capacity, we were relying heavily on PPE.
• 24:54
  SPEAKER_02: And then as the bottom started to fall out there a little bit, then we started relying more on testing.
• 24:58
  SPEAKER_02: So thinking about what trade-offs you're willing to make and where you really need to spend down some of those resources, hopefully not both at once.
• 25:07
  SPEAKER_02: And then I guess the last thing is there's much more evidence now, not all of it of the same quality, and trying to figure out where you stand and where you can develop consensus with other infection prevention leaders in your state or your city, because some of the bigger problems are we heard at such and such a hospital that they're using N95s for name your procedure, and that comes back, and then your staff feel unsafe.
• 25:33
  SPEAKER_02: So I think the more that we can build consensus across centers as much as we can and do things that make sense together, that's really helpful.
• 25:42
  SPEAKER_03: Thanks.
• 25:42
  SPEAKER_03: I love all the advice you provided.
• 25:44
  SPEAKER_03: I think, and as I reflect on our experience here, those exact decisions, the trade-offs, and the ability to be flexible as the supply chain allows, have been really such an important part of the response.
• 25:57
  SPEAKER_03: So I'll turn to you, Dr.
• 25:58
  SPEAKER_03: Milani, to wrap up any lessons that you want to share with our listeners who are beginning to encounter this at a higher level.
• 26:05
  SPEAKER_01: To echo on some of the aspects already mentioned, I think one of the biggest successes is really the ability for the healthcare industry to be nimble, not just, you know, our hospital, our system, but healthcare in general across the country.
• 26:19
  SPEAKER_01: You know, for an industry that is not known as being nimble, I think we have proved repeatedly that we can be, and we can change tremendously fast, we can adapt with new evidence.
• 26:30
  SPEAKER_01: And another thing that COVID has taught us, it's crucial to be humble, know what you don't know, and be able to pivot when we need to, which has often been the case up till now with COVID.
• 26:40
  SPEAKER_01: You know, if I would have told you within a few weeks, we would close most of our hospital entrances, screen every healthcare worker, mask every patient and colleague, develop a colleague hotline around COVID, fielding hundreds of calls daily, universally test all admissions and test prior to almost all surgeries and procedures.
• 27:00
  SPEAKER_01: And to do this within a small period of time, I think you know, most of us would say that that actually was not possible.
• 27:07
  SPEAKER_01: But that's actually what's happened at most hospitals and health systems.
• 27:12
  SPEAKER_01: The other thing I would say is thinking about the value of hospital epidemiology, infection prevention, infectious diseases, I cannot imagine a more exciting time to be involved with these areas.
• 27:26
  SPEAKER_01: And I think the value, the presence, you know, our relationships, it's never been higher.
• 27:32
  SPEAKER_01: And, you know, it's probably a very good time, realizing that many of us are quite busy, but to sort of preserve our bandwidth, to preserve our focus, to make sure that we're able to do the things that we need to do, it's also a really important time to sort of evaluate our programs and see where we are and think about structure and resources.
• 27:52
  SPEAKER_01: I think whatever sports metaphor you want to use, whether it's baseball, maybe we're in the third inning of maybe a game that goes into extra innings, or maybe it's football.
• 28:02
  SPEAKER_01: You know, we're nearing the end of the first quarter and maybe the game goes into overtime.
• 28:06
  SPEAKER_01: It's clear that right now we have the attention of hospital system leadership, and I think, you know, thinking about how we continue to meet the demand, what's coming, and making sure that we're able to do this successfully.
• 28:21
  SPEAKER_03: So thanks.
• 28:21
  SPEAKER_03: I think that's terrific advice.
• 28:23
  SPEAKER_03: This morning we just welcomed our new infectious disease fellows, and uh, they're starting today.
• 28:28
  SPEAKER_03: And I think what an amazing time to join into in the field of infectious disease.
• 28:33
  SPEAKER_03: So I want to thank you both again for uh coming onto the podcast, for sharing your perspectives and experiences, and a sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to COVID-19.
• 28:45
  SPEAKER_03: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 28:51
  SPEAKER_03: You will also find additional resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHAY COVID-19 town halls.
• 28:59
  SPEAKER_03: Additional resources available on learning CE pertinent to this pandemic include the SHAY CDC Outbreak Response Training Program, ORTP, and the prevention course in HAI Knowledge and Control Prevention Check.
• 29:12
  SPEAKER_03: This concludes this episode of the Rapid Response Podcast.
• 29:15
  SPEAKER_03: Thank you for tuning in.