COVID-19 is changing medicine in real time — and likely for good.
By Steve Graff
After intubating a patient one night in mid-April, M. Kit Delgado, MD, walked out of emergency department at Penn Presbyterian Medical Center (PPMC) for fresh air, pulled off his N95 face mask, and snapped a selfie that would find its way online, like the hundreds, if not thousands, of shots his fellow health care workers took in the thick of the COVID-19 pandemic for the world to see.
The deep red sores on their noses and the weary expressions in their eyes showed us, however briefly, just how exhausting and painful the trenches can be.
It was the humanity in their eyes that inspired perioperative nurse Marc Goldfarb, RN, BSN, to grab his smartphone to capture masked colleagues in similar moments at the Hospital of the University of Pennsylvania (HUP). In their eyes, he saw bravery after stepping out of COVID-19 units. He saw resilience up against emergencies they’d had no practice for. He saw sadness and concern as the virus took the lives of their patients, many without families by their side.
“We are real people doing a really stressful job,” Goldfarb said, “and this is what we look like.”
The photos have not only filtered into the public consciousness, Delgado’s selfie published in USA Today, Goldfarb’s photos shared to Penn Medicine’s Instagram followers and countless others. They’ve become historical artifacts; powerful reminders of what health workers have endured ever since the pandemic began. When the cases first hit, they rushed to the front lines, along with researchers on the hunt for answers, while others innovated ways to keep operations moving safely and often virtually.
By late spring, the early surge in Philadelphia-area hospitals had subsided, though nationally and globally, the coronavirus pandemic is still unfolding. But if a few months of facing down a pandemic crisis has left the Penn Medicine community confident about anything, it’s this: The ways of caring for patients, organizing work, and collaborating and conducting research together have been permanently changed—for the better.
Expanding Care Capacity
“Moving to the Next Music”: Readying Hospitals for a Surge
The rapid clinical and leadership response to build capacity for COVID-19 patients at Penn Medicine turned on hundreds of decisions every day at the onset of the pandemic.
Outside PPMC on March 17, Peter D. Sananman, MD, director of Disaster Preparedness and an associate professor of Emergency Medicine in the Perelman School of Medicine (PSOM), gathered up a team to erect a tent to triage patients before they entered the ER to reduce the risk of spreading COVID-19. By 4 p.m., the tent—which would go on to serve as a model for the other five hospitals—stood tall and ready to take patients.
Out in the suburbs, Penn Medicine Chester County Hospital (CCH), saw an opportunity to expand its inpatient care capacity. Five floors of the hospital’s new $300 million patient tower sat ready to go, slated for opening later in the spring. With emergency authorization from the state to use the tower for COVID-19 patients (the standard state inspection was sidelined by the pandemic), the CCH team readied an intensive care unit (ICU) and several surgical floors to care for patients.
Placing COVID care units in the new tower worked out well for both patient and staff safety, said Michael Duncan, CEO of CCH. Each ICU room was already cordoned off with glass, unlike the “legacy” ICU in the original hospital, and the floors were more spacious and nursing stations spread out, making it more suited for social distancing.
Although they were working in a new space, caring for COVID-19 patients still required creativity on the staff’s part, like engineering patient rooms to safely perform surgeries to help cut down on transport and reduce risk of infections. “It’s a little like watching a symphony where the sheet music changes every few bars and everybody just moves to the next music,” Duncan said.
Meanwhile, at HUP and PPMC, by the middle of April, there was a steady stream of COVID-19 patients, many arriving by ambulance, requiring evaluation, oxygen, critical care beds, and ventilators. On the HUP campus, leaders also took the step of accelerating construction to ready 120 rooms in the Pavilion, also known as HUP East, ahead of its scheduled completion date in 2021. By mid-October, more than 3,800 COVID patients had been admitted across all six of Penn Medicine’s hospitals, with a peak of about 400 patients at once in late April. Clinical staff worked tirelessly to care for them, with physicians, nurses, respiratory therapists, environmental service workers, and others constantly changing in and out of gowns to move from one to the next. “At that point in time it felt like it was all about mental and physical endurance,” said Delgado, an ED clinical researcher, “as we had more COVID-19 patients than any other type and everything took more effort and precaution.”
Ultimately, the extra space at HUP East was never needed, as the surge of patients never reached overwhelming levels, thanks in large part to multiple efforts across the health system to build capacity before and during the influx of COVID patients. Other scheduled surgeries and procedures were postponed, and many outpatient visits went online, with more than 5,000 clinicians leaping to provide virtual care.
“Absolute Must-Have”: The Right Care in the Right Places
From the sound of her labored breathing and her struggle to finish sentences, Sara S. Samimi, MD, an assistant professor of Dermatology at PSOM, knew the 23-year-old woman with asthma needed to be seen at the hospital. The patient was one of more than 27,000 who received phone calls from Penn Medicine clinicians like Samimi who were redeployed from their regular duties as operations shifted to support COVID care between March and June; she was working as part of one of several new telemedicine programs stood up at Penn during the pandemic, this one for communicating COVID test results. Positive tests led to discussions about potential clinical trial enrollment, coordinating care, and enrollment in another new telemedicine tool called COVID Watch that uses text messaging to support and monitor patients not sick enough for hospitalization.
Penn Medicine’s 24-hour hub-and-spoke telemedicine operation, the Center for Connected Care, is one of the largest in the nation. So when the pandemic hit, a well-oiled apparatus was already in place to provide continuous care for patients—including those who were safest staying out of the hospital while COVID cases were surging. It just needed to be supersized. Before, Penn coordinated roughly 200 tele-visits a month, mostly urgent care, ICU, or stroke consultations. In March, that number jumped to 7,000 a day—a 10,000 percent increase. Tele-licensed clinical staff also increased from about 500 to nearly 10,000, spanning disciplines that telemedicine previously hadn’t touched.
“It’s been a massive, massive ramp up,” said C. William Hanson, MD, the chief medical information officer and vice president at UPHS. “Telemedicine has gone from being a-nice-to-have to an absolute must-have.”
Not all care can be given over the internet, of course. Penn needed to go where patients were, and keep them out of the hospital when possible, so Penn Medicine at Home (PMH) took on a larger role. Already well-known for home health, palliative care, and hospice, PMH expanded its cancer care and infusion therapy services and took on new patients, like transplant and wound care, in addition to caring for COVID-19 patients at home. Staff either visit patients’ homes, check in virtually with the clinical team through video chats, or both.
“I see this as a period of tremendous development, growth and creativity,” said Nina R. O’Connor, MD, chief medical officer of PMH. “I think we are going to continue to see more of that because when patients experience care at home, and it’s safe and it’s comfortable, they often don’t want to go back to the infusion suite or the clinic visit.”
While the COVID Watch text-messaging program monitors positive or suspected patients at home with less severe symptoms, PMH cares for the sicker COVID-19 patients, including those discharged from the hospital. Since mid-March, more than 7,100 patients were monitored through COVID Watch, and more than 1,100 COVID-19 patients have been treated at home.
“If even half of them had been in the hospital at the peak of the surge, instead of at home, that would have really pushed capacity for the hospitals,” O’Connor said. “I think it was a very important component of taking care of the right patients in the right place during this.”
People Make It Possible
“Biggest Successes”: New Opportunities Amid a Pandemic
With many inpatient and outpatient services paused due to COVID-19 and the pressing need for workers on the front lines, people stepped up for new roles—often relying upon the health system’s robust collaborative systems to make that work seamless.
While dermatologists like Samimi took the lead on the telemedicine efforts, some downtown Philadelphia physicians traveled to Princeton Health to help on its front line. Infusion suite nurses from the Perelman Center for Advanced Medicine joined PMH. Human resources professionals coordinated the outpouring of food and other donations to support front-line staff, and many teams rapidly shifted at least a portion of their work to remote operations.
For perioperative nurse Goldfarb, who was redeployed to thermal scanning at HUP’s entrance and aiding clinicians on donning and doffing personal protective gear, it was his first time working outside the operating procedure room since he left nursing school more than 13 years ago. Ashley F. Haggerty, MD, MSCE, a gynecologic oncology surgeon, delivered five babies while picking up shifts at the HUP labor and delivery unit. “It was nice to reminisce back to my residency days,” she said, looking back on her OB-GYN training at HUP.
In all, roughly 500 people across the health system were redeployed, and more than 1,600 employees retrained to work in new positions, all coordinated through a virtual Workforce Redeployment Center created by Human Resources and the Penn Medicine Academy (PMA), as well as the COVID Learning Site. Developed by the UPHS COVID Learning Committee and PMA, that website houses the latest knowledge on COVID-19 anyone in the world can now access.
The HR team also had to stand up staffing processes for the health system to handle new needs COVID-19 had created, like thermal screening and COVID testing sites around the region, in what Lea Rubini, director of Change Management and Performance Improvement considers “one of the biggest successes of redeployment efforts.”
The shift in the workforce also forged new partnerships, as groups came together quickly to expedite tasks.
One example is the department of Pathology and Laboratory Medicine. Beefed up with support to handle the influx of COVID-19 tests, the team went from performing about six a day to nearly 3,000.
“We removed barriers around cultural change and system integration in a couple of weeks in what probably would have taken years,” said Cindy Morgan, vice president of Learning and Organizational Development.
“Idiosyncratic Experience”: Well-being of Staff Takes Top Priority
The pandemic has required mental stamina on everyone’s part to weather the challenges and stress it brings. But what helps ER physicians like Delgado and Sananman may look very different from the help other health care workers or Penn employees in non-clinical settings may need during these times. The trick was figuring out the components of what the Workforce Wellness Committee, led by Lisa Bellini, MD, senior vice dean for Academic Affairs, calls a stepped-care model that would provide a net as wide—and personalized—as possible.
“We know that stress is a completely idiosyncratic experience,” said Jody Foster, MD, chair of Psychiatry at Pennsylvania Hospital. “What stresses me out, might invigorate you. People are different.”
That led to the creation of PennMedicineTogether, a website layered with resources for staff and their families that address basic, physical, and emotional needs—everything from housing help and tips on homeschooling to exercise guides. It includes platforms like the Coping with COVID blog for people to ask questions anonymously and “Spread the Love” that allows users to post messages to front-line workers, which were also streamed on all the hospitals’ digital boards.
“It meant so much to [health care workers] to be able to see that one picture that a kid drew or that one message from the community, as they were taking off their PPE,” Bellini said. “It was pretty powerful.”
One of the most widely used digital tools is PennCOBALT. It’s a targeted assessment that takes users to the most appropriate resource or virtual face-to-face care for mental health and other support needs, so they don’t get overwhelmed with waves of information. It can also be used anonymously, which half do.
When the COVID crisis first started, the wellness team opted to dust off the near-complete COBALT that Cecilia Livesey, MD, chief of integrated psychiatric services in Psychiatry in PSOM, and Kelley Kugler, MSc, innovation manager at the Center for Health Care Innovation, had been working on for nearly three years.
When COVID hit, it took them two weeks to finalize plans and stand it up. And it’s here to stay. COBALT proved its value quickly, given the number of people who have accessed it (more than 7,000) and the advantages it affords patients, like privacy and convenience, two barriers that keep many people from seeking care.
“I really feel this has fundamentally changed how people are going to access mental health care in the future,” Bellini said. “The concept of going to a psychiatrist’s office—I’m not sure what that means post-COVID.”
Building the Post-COVID Future
“One Step Further”: Lasting Transformation of Health Care in a COVID-19 World
It took a pandemic to kickstart what some systems had been wanting to do for years. At Penn, it’s not only rocketing telemedicine into a new stratosphere and removing institutional barriers, it’s also shifting care practices.
The first goal after the spring surge subsided has been to rebuild trust, as the hospitals saw dwindling numbers of COVID-19 patients and began to reopen their doors to resume routine services for others. Stories from around the country of patients turning down life-saving procedures or avoiding emergency care out of fear of COVID-19 underscore how important it is for the health system to not only tell patients it’s safe to come back but also show them.
It takes an open line of communication between patients and the physicians they trust, a continued focus on hygiene and handing washing, screening staff and patients before entering, and universal masking, said Alyson Cole, an associate executive director at HUP and co-chair of the Patient Experience Leadership Team.
“A lot of it is assurance,” Cole said, “and then when they get here making sure we are delivering on what we promised.”
Clinical teams have also started to think about how care may look on a more permanent basis in a COVID-19 savvy world.
The expansion of telemedicine has largely been seen as a positive and convenient feature to keep patients and providers connected during these times. But the benefits could branch out beyond that. Virtual care could help raise the threshold for admissions, triage more efficiently, even for high-risk patients, expedite care, add convenience, and maintain more privacy. The list is long.
“I do think it’s a substantial part of the future of health care,” said David Asch, MD, MBA, executive director of the Center for Health Care Innovation. “And it took a pandemic to help us get there faster because there are so many regulatory and financial headwinds under normal circumstances.”
The problem is that the health insurance industry worries that if telemedicine makes necessary care easier, it can also make unnecessary care too easy, Asch said. So insurers often require that health care be delivered face to face in order for health care providers to be reimbursed for their services. “That’s perverse,” he said. “The answer can’t be to make all care harder. If the care is needed, it shouldn’t matter if it’s delivered over the [internet] or in person. Every other industry advances by making its services easier to receive, not harder.”
Waiting rooms and food areas, along with clinical space, could also take on a new shape, so it’s safer and more convenient for patients. Early on, HUP designated an area to COVID-19 patients, turning entire floors into negative pressure areas. While these spaces have scaled back as the number of patients has decreased in the hospitals, some form of an infectious disease unit will likely be a mainstay in hospitals to keep patients in a separate area in the event of another outbreak.
Leaning more heavily on mobile technology used during the pandemic to reduce wait times in the clinic or ER could become a reality, as well.
“There are so many silver linings to this where innovation has truly happened rapidly,” Cole said. “What we are trying to do right now is capture that and continue to bring it forward.”
“All Hands On Deck”: Researchers Band Together to Push the Science
For every outbreak—HIV, Ebola, Zika—Penn Medicine has initiated new research. COVID-19 was no different, except the efforts materialized at unprecedented speed and folded in researchers from far more disciplines.
“Within a matter of about two-and-a-half weeks, we went from no trials to 11 clinical trials, and have since added [more],” said Emma A. Meagher, MD, vice dean and chief clinical research officer, and co-chair of the COVID-19 research oversight committee. “It was all hands on deck.”
By the time Penn admitted its first COVID-19 patient in early March, clinical trials with the antimalarial drug hydroxychloroquine and the antiviral drug Remdesivir were already up and running. Others followed, like a trial designed around heart failure patients, an observational study gathering up biospecimens, and studies investigating antibodies and immunity in health care workers and the community.
Ravi K. Amaravadi, MD, an associate professor of Medicine, who has been studying hydroxychloroquine as a cancer therapy for the last decade, shifted over to COVID-19 to lead that trial. E. John Wherry, PhD, director of the Institute for Immunology and chair of Systems Pharmacology and Translational Therapeutics, is immunoprofiling patients to tease out the different responses in sick patients and partnering with Nuala J. Meyer, MD, an associate professor of Medicine, in rapid translational efforts to inform their care—trading insights and inquiries between lab and clinic on a daily basis.
Meanwhile, work on DNA-based vaccines presses on with David B. Weiner, PhD, an emeritus professor in the PSOM, and Pablo Tebas, MD, a professor of Medicine, while an RNA-based vaccine work continues under the auspices of Norbert Pardi, PhD, a research assistant professor of Medicine, and Drew Weissman, MD, PhD, a professor of Medicine.
The clinical research efforts are paired with a full pipeline of basic science expertise through the work of Susan Weiss, PhD, a virologist and professor of Microbiology who has spent the last 40 years studying coronaviruses and was named the co-director of the Penn Center for Research on Coronavirus and Other Emerging Pathogens with Microbiology Chair Frederic Bushman, PhD. Penn Medicine’s Gene Therapy Program, led by James M. Wilson, MD, PhD, is also conducting vital preclinical studies of a unique gene-therapy-based vaccine candidate.
“What is really striking here, mainly because of the existential threat to all of us, is that people across the spectrum of medicine and science, way beyond infectious diseases, virology, epidemiology—everybody, including myself—has gotten mobilized,” said Garret FitzGerald, MD, FRS, a professor of Medicine and Systems Pharmacology and Translational Therapeutics, who chairs the oversight committee. “[They said,] ‘What can I do? What bright ideas can I bring to the table?’”
Pouncing on the virus has paved the way for how future science will be conducted.
The multidisciplinary approach to infectious diseases will likely grow, but expect the focus on zoonotic diseases and collaborations with Penn Vet to intensify, FitzGerald said, along with even stronger translational science—Penn’s “sweet spot,” he said—and more private partnerships to get clinical trials off the ground faster.
“I also think the issues around trial design are more acute than they ever have been before,” Meagher said. “If anything, there has been an increased focus on the right research question, the right patient population, the right sample size, and the right end point.”
How those trials are conducted may change, too. Working within the safety constraints of COVID-19 has shown that remote consenting and testing and delivering experimental medications to a patient can be done without weakening the study’s integrity. And it lightens the burden on patients and research teams.
What Meagher doesn’t want to lose is steam.
“Everything we have been doing since March 1 has been so intensely focused on COVID, and it’s exhausting, but I would like to see some part of that transmit beyond this very intense period,” she said. “Where it becomes part of our practice.”