The AAMC continues to monitor guidance from the Centers for Disease Control and Prevention (CDC) state and local health agencies as it relates to the coronavirus (COVID-19). We will continue to update our coronavirus resources page as more information becomes available.
At Emory Healthcare, students and residents not involved in the direct care of patients with tuberculosis (TB) and other highly communicable diseases are being asked not to enter the rooms of these patients in order to conserve N95 respirators, which are in short supply across the country.
At the University of Nebraska Medical Center (UNMC), senior medical leaders are actively mapping out contingency staffing strategies if 30%-40% of the health care workforce could not come to work — a possible scenario if the new coronavirus spreads as widely in the United States as it has in China.
At University of Louisville Health (ULH), medical school leaders met this week to discuss how they might continue to educate their 800-plus students through teleconferencing and online learning portals should an outbreak necessitate the closure of the medical school.
And at the University of Washington Medical Center (UWMC) in Seattle, currently the epicenter of the outbreak in the United States, frontline workers — including emergency department providers, anesthesiologists, hospitalists, critical care personnel and respiratory therapists — have received just-in-time training in the donning and doffing of personal protection equipment (PPE). UWMC, like many other teaching hospitals, has also activated its incident command center to ensure that senior leaders across the system communicate daily (and sometimes several times a day) on the latest developments.
These are just a few of the many activities taking place at academic medical centers across the country, as teaching hospitals prepare for the possibility that COVID-19, which has thus far killed 14 and infected close to 225 Americans in 18 states, will spread widely across the United States. At the same time, many are urging worried patients — and their own staffs — to stay calm, remember that the best infection control practices are hand washing and avoiding contact with people who are sick, and feel confident that health care workers across the country are mobilizing to handle any widespread epidemic.
“Academic medical centers are well-equipped to handle outbreaks of this kind,” says Jason Smith, MD, PhD, MBA, chief medical officer of ULH. “We have not just the protocols in place to identify unknown infectious pathogens, but we have the equipment we need to treat patients.”
Planning for a pandemic
Emory and UNMC are two of the 10 academic medical centers around the country with enhanced capacity to care for patients with highly infectious diseases. Indeed, they can be ready within eight hours to receive an infected patient, and UNMC has already treated 15 U.S. patients with COVID-19, most from the Diamond Princess cruise ship, says Shelly Schwedhelm, MSN, RN, executive director of emergency management and biopreparedness. Of those patients, five have been released, nine are being housed in the hospital’s quarantine unit, and one is still in the biocontainment unit (BCU) — a negative-pressure ward on the hospital’s seventh floor that is equipped with special technology to limit the spread of the virus. UNMC and Emory both successfully treated health care workers who contracted Ebola while working in West Africa in 2014, and while COVID-19 is not as deadly as Ebola, health care workers are still being cautious.
The challenge with this novel coronavirus, says William Bornstein, MD, chief medical officer and chief quality and safety officer for Emory Healthcare, is that nobody knows just how many patients will need treatment. “What we know, and this was reinforced during the Ebola situation, is while it’s great having that [biocontainment unit], the more important aspect of this is staff training. How you don and doff PPE and all of those small details are very challenging. One of the reasons we were successful with Ebola without any of our staff becoming infected was because the only people who came into contact with those patients were those who had special training.”
In preparation for an influx of patients with COVID-19, Emory is working to rapidly train those front-line workers, including emergency department and critical care unit staff. “We’re prioritizing first points of contact and areas of greatest exposure,” Bornstein says. Training includes proper fit testing of N95 respirators (and then reusing those respirators to conserve the supply). “We have inventory conservation steps in place so that we can reuse masks when appropriate, even as our supply chain people are out there working to secure additional equipment.”
Inventory conservation is being deployed at UWMC as well, where training that might previously have included the physical donning and doffing of PPE is now done via demonstration to not use up precious resources, says Christopher Kim, MD, MBA, associate medical director for quality, patient safety and clinical efficiency. As part of that training, staff are provided with the information to watch a video produced by the National Ebola Training and Education Center. “We started our training efforts with a focus on front-line provider groups, and then moved on to training other specialties after that."
Like Emory, UWMC is minimizing the number of providers who come in direct contact with patients and patients under investigation (PUI) who are suspected of having the pathogen. They are also launching a site-based test so that every PUI can be tested immediately without having to send samples to the Centers for Disease Control and Prevention.
Because UWMC is in the midst of the hardest-hit area in the country with possible community spread, university leaders are also taking a strict stance on what to do if you’re sick. “As a health care worker, if you develop any symptoms, not just COVID-related but any respiratory symptoms, you need to not come into work,” says Byron D. Joyner, MD, MPA, vice dean of graduate medical education and designated institutional official at the UW School of Medicine. “The culture of medicine is to be accountable and responsible and dedicated and committed. Right now, accountability is manifest by not coming in when you’re sick. We need to stress that. We have to change our culture, and this might be that moment.”
Anticipating that large numbers of health care workers could be out sick is part of the pandemic preparedness preparations at UNMC. “We have been planning for potential pandemics for years, but in the last six weeks, we have started modeling for certain scenarios,” Schwedhelm says. “We’re working on what the staffing strategy would be if 30% or 40% of the workforce could not come to work. Our support services team is looking at what food is on hand, how waste management plans will be altered, how we keep our emergency departments from being overrun.”
At the University of Missouri School of Medicine, medical leaders are setting up a telehealth service within the emergency department specific to the coronavirus so that patients can call in to ask questions and health care providers can ascertain whether a patient should come in for treatment, says Victor Arnold, executive director of University Physicians. “We have gotten a ton of EHR portal queries, and this is a way to re-channel those queries and act faster.”
The role of residents
Because academic medical centers employ large numbers of residents and educate thousands of medical students, the roles of trainees are also being discussed. At UWMC, 1,400 residents are employed across four medical centers within the UW’s five-state region. Residents make up about one in every six physicians in that system, says Joyner, and as such are considered “essential personnel.” “They are essential and should be able to be on the front lines with the proper supervision,” Joyner says. “For example, residents and fellows in pulmonary and critical care, because of what they do, should be on the front lines.”
At Emory, internal medicine residents, general pediatric residents, and critical care fellows are being trained first, along with house staff, in proper PPE donning and doffing. “These residents will be much more integral to the care of these patients,” says William Eley, MD, MPH, executive associate dean for medical education and student affairs at Emory University School of Medicine. “They are front line care with excellent attending supervision.”
If the virus spreads as widely in the United States as it has in China, “we think the residents will be caring for patients at some point,” Eley says. That said, the fewer number of people who are involved in treating any initial wave of patients, “the more successful you will be in containment.”
“We have a crackerjack team of highly trained staff at Emory,” Bornstein says. “Right now, we would not have residents taking care of these patients. If this scales up and our hospital is full of patients, it remains to be seen how all of this will play out.”
Looking out for students
Across the country, 90,000 medical students are being trained at more than 150 medical schools. This is a pivotal moment for them, as they see how academic medicine is gearing up to treat patients with an illness about which so little is known.
Most academic medical centers have no plans to mobilize students to care for patients, but many are anticipating that students may be asked to stay home. “We are working with our downtown campus and our healthcare center campus to figure out how we continue educating our students,” Smith says. “Already, we have small group meetings where you have teleconferencing, but how do we expand that.”
At the University of California, San Francisco, School of Medicine, senior leadership have even begun discussing how they might accommodate changes in graduation requirements, so that if schools are shut down, students can still graduate on time. “There may be some period of time when students would be away, so how can we add that time back without delaying graduation?” asks John Davis, MD, associate dean for curriculum and professor of infectious diseases.
Third- and fourth-year medical students who are doing clinical rotations in the hospital may face special challenges.
The AAMC has developed guidelines around the role of medical students and COVID-19 in health care settings that include a recommendation that if the outbreak becomes widespread, schools should consider suspending introductory clinical rotations “until the epidemiology of COVID-19 is better known and the burden on front line care providers from COVID-19 patients has diminished.”
For students in core clinical clerkships and clinical electives, the guidelines acknowledge that students are regularly involved in the care of patients with communicable diseases like influenza, measles, TB, and HIV. However, given the lack of critical data about the transmissibility of COVID-19, the guidelines state that “it may be advisable, in the interest of student safety, to limit student direct care of known or suspected cases of COVID-19 until better epidemiologic data are available. We suggest that, other than limiting direct care of COVID-19 patients, clinical students continue their roles as part of the care team.”
“As a health care community, we are learning daily about COVID-19,” says Alison Whelan, MD, AAMC chief medical education officer. “Your policies and our recommendations will likely change as our knowledge develops. When academic medicine is faced with challenges, we do our best work when we share with each other and support each other.”
The AAMC is also in close contact with Vice President Mike Pence’s office to offer resources, and with the Office of the Assistant Secretary for Preparedness and Response to help communicate supply chain problems and get ahead of shortages, says Janis Orlowski, MD, the AAMC’s chief health care officer.
The AAMC has also decided to cancel several of its upcoming professional development meetings, even as several large academic medical centers, including New York University and Columbia University, have banned travel for hospital staff until the outbreak is under control.
Most academic medical centers also are following the CDC recommendations regarding travel to Level 3 countries where the coronavirus is widespread. These include China, South Korea, Italy, and Iran.
The CDC also maintains a website with the latest guidance for health professionals and the public on the coronavirus, and Johns Hopkins University has developed an interactive web-based dashboard that tracks global cases of COVID-19 in real time, including countries affected and the number of deaths and recovered patients in each location. In addition, the AAMC has posted a collection of resources and other content related to the coronavirus on its website.
“This is very much the dominating activity every day,” says Bornstein, who notes that Emory has implemented its organization-wide plan to deal with a large-scale outbreak. That includes twice-daily readiness huddles that roll up to the executive level, in addition to the accelerated training of staff who are likely to be on the front lines. “As soon as we became aware of this novel coronavirus, we have been preparing for this,” he says. “We also have internal experts that are national resources for helping other institutions with their preparedness planning.”
Smith adds: “If you think about the bread and butter of what we do in academic medicine, it’s treating patients who are seriously ill, researching treatments and vaccines, and setting up systems to respond to these threats. This is what we do.”