{"id":3262,"date":"2021-10-18T16:23:37","date_gmt":"2021-10-18T16:23:37","guid":{"rendered":"https:\/\/medschool.prd.vanderbilt.edu\/vanderbilt-medicine\/?p=3262"},"modified":"2021-10-22T20:31:09","modified_gmt":"2021-10-22T20:31:09","slug":"what-the-pandemic-is-teaching-us","status":"publish","type":"post","link":"https:\/\/medschool.vanderbilt.edu\/vanderbilt-medicine\/what-the-pandemic-is-teaching-us\/","title":{"rendered":"What the Pandemic is Teaching Us"},"content":{"rendered":"
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Illustration by iStockPhoto.com<\/figcaption><\/figure>\n

It\u2019s too soon to call an end to COVID-19, the worst worldwide pandemic in 100 years, which has killed as many Americans as the 1918-19 flu. The slow\u00a0uptake of effective vaccines has enabled the causative virus, SARS-CoV-2, to continue to evolve in dangerous and easily transmissible ways.<\/p>\n

But it\u2019s not too early for health care providers, their trainees and those engaged in biomedical research to take stock. What did they do well? Where did they fail? That kind of reflection, that tallying of lessons learned \u2014 or ignored \u2014 will help us finally put an end to the present pandemic and prepare for the next one. Key decision makers and stakeholders at Vanderbilt University Medical Center (VUMC) weigh in on takeaways that are likely to have a lasting impact on patient care, education and research.<\/p>\n

Offer holistic, compassionate care<\/strong><\/p>\n

From the get-go VUMC had to manage its workforce adroitly, given that a preexisting national nursing shortage was suddenly exacerbated by those who had to quarantine after testing positive for SARS-CoV-2. A labor pool was set up, and employees were cross-trained to adequately staff clinical areas of greatest need.<\/p>\n

The challenges were immense. To prevent the spread of infection, family members could not visit the bedsides of critically ill loved ones, while exhausted staff faced burnout. As admissions increased, faculty and resident physicians from nearly every specialty filled unfamiliar roles as did registered nurses, nurse practitioners, physician assistants, respiratory therapists and other front-line workers.<\/p>\n

Months into the pandemic, more than 50 physicians from across the Medical Center had volunteered to communicate with family members of patients in the COVID-19 ICU so their fellow physicians and nurses could focus on direct patient care.<\/p>\n

\u201cPatient care at the bedside is priority,\u201d said Kyla Terhune, MD, MBA, associate dean for Graduate Medical Education. \u201cHowever, for a family member waiting at home for any news regarding their loved one, having someone who is totally dedicated to communicating to them is just as critical. It\u2019s holistic, compassionate care.\u201d<\/p>\n

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Kyla Terhune, MD, MBA, established a balanced approach to leadership and support for trainees during the pandemic, earning a Five Pillar Leader Award. Photo by Donn Jones.<\/figcaption><\/figure>\n

Early in the pandemic and until personal protective equipment became more widely available, medical doctors who specialize in providing care in the hospital, called hospitalists, treated all COVID-19 patients admitted to VUMC except those in the intensive care unit.<\/p>\n

Physicians and advanced practice providers from the Section of Hospital Medicine also trained others in COVID-19 care, supervised the post-discharge monitoring program, COVID-2-Home, and helped identify and enroll patients in clinical trials, said section chief Eduard Vasilevskis, MD, MPH, associate professor of Medicine.<\/p>\n

Elsewhere, nonclinical staff members learned to register and transport patients, work in the lab, unpack and distribute supplies, and perform other nonclinical duties.<\/p>\n

Executive leaders of the Medical Center \u201cpitched in and were seen cleaning rooms, transporting patients and delivering trays,\u201d said Mark Sullivan, PharmD, MBA, executive director of VUMC Inpatient and Clinical Pharmacy Operations. \u201cThe visibility of our leadership \u2026 kept us all calm and focused on the job at hand.\u201d<\/p>\n

\u201cIt was an amazing experience,\u201d added April Kapu, DNP, APRN, who was associate nursing officer for advanced practice at the time, \u201cseeing the Vanderbilt Valet team helping to temperature-screen visitors, pediatric nurses working in the adult acute care units, nurse practitioners and resident physicians taking hotline calls, and so many others who were quick to jump in and help \u2026 in new and unfamiliar ways.\u201d<\/p>\n

Similar adjustments were made in the residency training programs. At any one time more than 1,000 resident physicians \u2014 medical school graduates \u2014 are receiving specialty training at VUMC in internal medicine, pediatrics, obstetrics and gynecology (OB-GYN), surgery, anesthesiology and other disciplines.<\/p>\n

Very early on in the pandemic, Terhune, in concert with the residency program directors, created an inventory listing the expertise and critical care experience of each trainee.<\/p>\n

\u201cThat allowed us very quickly to staff up or staff down inpatient services,\u201d said John McPherson, MD, the Drs. Sol and Marvin Rosenblum Professor of Medicine and director of the Internal Medicine Residency Program.<\/p>\n

As most patients who were severely ill with COVID-19 were treated on the medical units, at first the burden of caring for them fell primarily on the internal medicine residents. Six months into the pandemic other residents came in to relieve them, \u201cwithout any prompting from us,\u201d McPherson said.<\/p>\n

\u201cTeams from Surgery, from Anesthesiology, from OB-GYN, from all of the other programs came in and staffed these units to allow our residents to take a break and to minimize the disruption to their training,\u201d he said.<\/p>\n

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Adapt technology<\/strong><\/p>\n

Information technology was a key part of VUMC\u2019s COVID-19 response. At the beginning of the pandemic, most meetings and clinics moved online to curtail the spread of the virus. How to continue to provide \u201chands-on\u201d learning to resident physicians was a particular challenge. In the Emergency Medicine program, for example, \u201cyou can\u2019t really have a virtual chest tube clinic,\u201d said Matthew Pirotte, MD, associate professor of Emergency Medicine. \u201cAt some point you have to put your gloves on.\u201d<\/p>\n

On the other hand, \u201cvideo conferencing is a pretty decent format for a didactic lecture. We are definitely toying with the idea of having some virtual conference modules going forward,\u201d he said.<\/p>\n

\u201cOur students and residents may feel (perhaps appropriately) that they may not have gotten the \u2018normal\u2019 experience,\u201d added Sullivan, who directs the residency program in Health System Pharmacy Administration. \u201cBut they got an experience that trainees haven\u2019t seen in our country since the 1918 flu outbreak.<\/p>\n

\u201cThey will be more resilient,\u201d he said, \u201cmore aware of the gift of health and the value of evidence-based science, perhaps, than their colleagues who came before them.\u201d<\/p>\n

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Residency program recruitment pivoted to online interviews during the pandemic, which could be a viable option going forward, says Rebecca Swan, MD. Photo by Susan Urmy.<\/figcaption><\/figure>\n

The recruitment of medical school graduates into residency training programs transformed. Switching to online interviews \u201cleveled the playing field,\u201d said Rebecca Swan, MD, professor of Pediatrics and director of the Pediatric Residency Training Program at the time. \u201cWe were able to talk to some really talented students who may not have been able to fly from the other side of the country.<\/p>\n

\u201cDid that really change who we recruited? Come back to talk to me in three or four months, and I\u2019ll tell you,\u201d Swan said. In the meantime, prospective pediatric residents will continue to be interviewed online.<\/p>\n

One of the most profound impacts of the pandemic was the acceleration of telehealth \u2014 the movement of the traditional in-person office or clinic visit online.<\/p>\n

With the urgent need to protect patients from being exposed to the virus, by the height of Nashville\u2019s pandemic \u2014 in late 2020 and early 2021 \u2014 many VUMC clinic visits were being conducted virtually.<\/p>\n

Patients were also encouraged to enroll in My Health at Vanderbilt, VUMC\u2019s telehealth portal, where they could schedule their doctors\u2019 appointments, refill prescriptions, view test results and obtain a wide range of health-related information.<\/p>\n

For some service lines, such as behavioral health, where 65% of clinic visits are still held online, telehealth has become the new norm. \u201cIt is very convenient for the patients,\u201d said Health IT Chief Information Officer Neal Patel, MD, MPH, professor of Clinical Pediatrics.<\/p>\n

Telehealth probably would have happened anyway, but the pandemic \u201cforced us to move quickly to adopt ways of doing things differently,\u201d he said. \u201cWe have become a digital world.\u201d<\/p>\n

The pandemic also accelerated advances in post-discharge care and other areas, Vasilevskis added. \u201cIt was wonderful to see how fast mountains could be moved,\u201d he said, \u201c… when hospitals, local governments and the health care system (worked) together.\u201d<\/p>\n

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Rely on research<\/strong><\/p>\n

Much of that \u201ctransformational energy\u201d came from the research community, observed William Schaffner, MD, professor of Preventive Medicine in the Department of Health Policy and professor of Medicine in the Division of Infectious Diseases, and among VUMC\u2019s most frequently quoted COVID-19 experts.<\/p>\n

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William Schaffner, MD, says investment in research will serve VUMC and the nation well during the next, inevitable pandemic. Photo by Donn Jones.<\/figcaption><\/figure>\n

At the national level, Kathryn Edwards, MD, Marie Griffin, MD, MPH, and H. Keipp Talbot, MD, MPH, served on panels that provided scientific oversight of vaccine trials and developed recommendations for vaccination policies.<\/p>\n

Mark Denison, MD, director of the Division of Pediatric Infectious Diseases, and his group applied a wealth of information about coronaviruses they had amassed over the years to evaluate and ultimately demonstrate the effectiveness of remdesivir, the first antiviral drug authorized for emergency use in patients hospitalized with COVID-19.<\/p>\n

James Crowe Jr., MD, director of the Vanderbilt Vaccine Center<\/a>, and his colleagues pioneered the development of monoclonal antibodies, which by neutralizing the virus with laser-like precision can prevent infected patients from becoming seriously ill.<\/p>\n

Buddy Creech, MD, MPH, director of the Vanderbilt Vaccine Research Program<\/a>, led clinical trials that contributed to the rapid development of the first COVID-19 vaccines authorized for emergency use in the United States.<\/p>\n

The Vanderbilt Institute for Clinical and Translational Research<\/a> helped lead a national effort to \u201crepurpose\u201d drugs used for other health conditions to relieve symptoms and improve outcomes from COVID-19.<\/p>\n

One of those drugs, hydroxychloroquine, used to treat certain rheumatologic conditions and malaria, was found not to be of significant benefit to hospitalized COVID-19 patients, despite preliminary evidence to the contrary.<\/p>\n

\u201cThis was a test of how efficient our clinical research infrastructure could be in an emergency,\u201d said Wesley Self, MD, MPH, who led a national trial of hydroxychloroquine funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health.<\/p>\n

\u201cA large, high-quality, clinical trial to evaluate a drug like this would often take a year or more to design and launch,\u201d said Self, associate professor of Emergency Medicine and vice president for Clinical Research Networks and Strategy at VUMC. \u201cThe COVID-19 pandemic did not allow for this type of time.\u201d<\/p>\n

So the clinical trials team at VUMC swung into action. On April 1, 2020, just 13 days after the idea for the trial was conceived, the first patient was enrolled at VUMC. Within 78 days, the study had enrolled 479 patients from 34 hospitals across the country.<\/p>\n

There is no reason for a pandemic to push providers to adopt practices prematurely before they have been adequately tested. \u201cThe clinical research infrastructure can be incredibly efficient when faced with an emergency,\u201d Self said.<\/p>\n

And yet COVID-19 also has put a strain on \u201cpeer review,\u201d the long-established system by which qualified \u201cpeer\u201d researchers review their colleagues\u2019 studies before they are published in a scientific journal.<\/p>\n

The problem is, there simply are not enough peers who are willing to give up some of their time in the laboratory or clinic to review the findings of others. The avalanche of studies propelled by the pandemic has only exacerbated this shortage.<\/p>\n

Peer review has its function and \u201cright now that function is really being challenged and overwhelmed,\u201d said Robert Carnahan, PhD, associate professor of Pediatrics and associate director of the Vanderbilt Vaccine Center where much of the monoclonal antibody work is conducted.<\/p>\n

While the pandemic has exposed weaknesses in the scientific review process, overall the nation\u2019s research enterprise, and VUMC in particular, \u201ccontributed mightily\u201d on three levels, Schaffner said.<\/p>\n