How do we know when the second wave is starting? What should we expect? These are only two of the questions Dr. Chad Kessler, National Program Director for VHA Emergency Medicine, asked during a recent COVID in 20 interview with VA Infectious Disease and Epidemiology wizards, Michael A. Gelman, M.D., Ph.D., and Gio Baracco, M.D., from James J. Peters VA Medical Center in the Bronx, New York and Miami VA Healthcare System in Miami, Florida respectively.
Despite the pictures and videos of full beaches and crowded boardwalks, our experts aren't sure the first wave is over. In New York, for example, where the Bronx was really the epicenter of the pandemic in the U.S. with the highest death rate per capita, we saw a peak and a decline. But according to Dr. Gelman, there is still a significant number of patients with COVID-19 in our hospitals.
“People talk about the September surge because you get a nice alliteration with it, but at the same time, we need to be aware that the wolf is always at the door,” said Dr. Gelman. Outside of New York and a few other hot zones, it's been a bit different. Dr. Baracco believes we had a blunted first wave in those areas.
“In most places, we've had a ‘wavish' of sorts,” said Dr. Baracco. “As we see a relaxing of some of the things put in place, we might see a second peak of the first wave more than a second wave just yet.”
Testing capabilities have improved, and VA has implemented safety measures to protect patients and staff. These are among the reasons our experts believe VA is better prepared to identify the disease and safely care for Veterans if this second peak arrives.
“Now we know what we're looking for, how the patients present, and we have testing capabilities that we didn't have a couple of months ago. We are are much better prepared to receive a surge of patients than we were even just a few weeks ago,” said Dr. Baracco.
The first time around, according to Dr. Gelman, in New York, Seattle and New Orleans it seemed to have snuck up on people.
“It was ‘it's not here, it's not here, it's not here, oh it's everywhere',” said Dr. Gelman. “We've seen this play out and we need to evolve rapidly and dynamically as prevalence changes. When a stampede of zebras comes over the horizon you need to quickly stop thinking about horses.”
Earlier this month, VA began to reintroduce services at select locations, based on national, state and local guidance. Dr. Kessler asked our experts what VA is doing to keep patients and staff safe.
Dr. Gelman is confident VA is using its experience over the past three months and sharing strong practices across its network to be better prepared for a second peak, a second wave and for reintroducing services for Veterans who need care today.
“We've had practice doing this once,” said Dr. Gelman. “Having testing and keeping your clinical suspicion higher than baseline is going to be important. Individual cases happen before the large numbers,” added Dr. Gelman. “Having that low threshold to do testing will help with detecting an uptick before things get out of hand.”
Dr. Baracco points to the layers of protection VA has implemented. The idea is that we don't focus too much on just one thing. Every single intervention, every single layer that we put in place is, by definition, imperfect. The build of one on top of the other is providing that group protection we need.
“We've spent the last three months or so thinking about this question,” said Dr. Baracco. “How do people receive the care they need, at the same time protecting everyone involved – both patient and staff members. We build layers upon layers of protection into our system. We start with shifting what we can safely shift to virtual care. The absence of contact is the best protection,” added Dr. Baracco.
“But there are some people who are going to need to be seen. We start by screening individuals; we implemented universal masking; we have environmental management; we have hand hygiene; we have physical distancing; we build our systems so that people don't congregate,” according to Dr. Baracco. “All of those things are so that we can take care of patients safely.”
Those layers of protection are put in place to keep both patients and staff safe. Additional measures are required for patients who have symptoms, need high-risk procedures, and high risk patients including those living in VA's Community Living Centers and spinal cord injury treatment units.
“For those we target other strategies like testing, additional PPE, additional screening and testing for asymptomatic patients and staff.”
As we start to reintroduce services, our experts agree that VA will need to continue to innovate and be willing to look at the care model a bit differently as we move forward.
VA has been a leader in providing virtual care, quickly shifting Veteran appointments from inperson to video and phone meetings to ensure Veterans continue to receive the care needed while minimizing risk. Dr. Gelman suggests, however, that as we move to the next phase in this pandemic, it might require a totally new way of looking at the traditional doctor's visit.
“Virtualization is going to involve unbundling the visit. Taking the components of what we traditionally thought of as a single encounter – history, physical exam, tests, studies, counseling, diagnosis, prescriptions – and atomizing them into smaller units,” said Gelman.”
The new model, according to Dr. Gelman, could include using video or even telephone for some of these pieces to limit the amount of face-to-face time with a provider to those items that really need to take place in-person. This, in turn, could mean that the entire health care system both within and outside of VA would need to re-envision how productivity and workload are measured.
Dr. Baracco reminds us that as we reintroduce services, we are dealing with a different risk profile. “When we started three months ago, we were teaching people how to care for COVID patients. Now we're teaching people how to treat non-COVID patients in a COVID era,” said Dr. Baracco. It truly is a different mindset.
To watch or listen to the entire interview and past interviews go to the COVID in 20 SharePoint site. Be sure to join Dr. Chad Kessler, National Program Director for VHA Emergency Medicine every Tuesday and Thursday at 4:30 ET using Adobe Connect: http://va-eercees. adobeconnect.com/emmeet/ or by phone, at 1 800 767 1750, 12328.
Michael Gelman, M.D., PhD, is an Infectious Disease specialist who leads Infection Controland Antimicrobial Stewardship at the James J. Peters VA Medical Center in the Bronx, NY (the county with the highest per capita COVID-19 death rate in the US), where he was selected as 2020 Physician of the Year - Partner in Collaboration before the pandemic wave. He has been the VISN 2 High Consequence Infection lead, responsible for pandemic preparedness at VA in New York State and New Jersey, since 2017 and has been part of VA's national response to COVID-19 since late January 2020. He is an Assistant Professor in the Division of Infectious Diseases, Icahn Mount Sinai School of Medicine, and an Assistant Clinical Professor of Medicine at Columbia University.
Gio Baracco Lira, M.D., is an Infectious Disease physician and hospital epidemiologist. He is the Chief of Infectious Disease at the Miami VA Healthcare System and Professor of Clinical Medicine in the Division of Infectious Diseases, University of Miami Miller School of Medicine. He is the VISN 8 lead infectious disease and infection control subject matter expert and has been involved in various pandemic preparedness efforts at the local, VISN, and VACO levels since 2005.
This post was shared from COVID in 20 a semi-weekly podcast by Dr. Chad Kessler. Download Adobe Connect at no charge to connect.
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