All together now
Stanford Medicine takes aim at COVID-19
It was Friday, Jan. 24, and Amanda Chawla, vice president of supply chain for Stanford Health Care, was knee-deep in a crisis when a colleague relayed a question that gave her pause.
“Do you think we’re going to have a problem with this?”
The question had been posed by a nurse who was following the news out of China. Wuhan had just instituted a citywide quarantine that shut down medical supply manufacturing in the region.
“The nurse knew that the Hubei province is a major manufacturing hub for medical supplies, including personal protective equipment,” Chawla recalled.
Chawla and her colleagues realized immediately that the threat was very real.
Like many other major medical centers, Stanford is on a “just in time” model of medical inventory distribution, including personal protective equipment. As a result, there is rarely more than about three to five days’ worth of supplies directly on hand: not enough to combat a worldwide run on manufacturers sparked by what could be a global pandemic.
“Our core mission is to ensure the right items are in the right place at the right time,” Chawla said. “It was clear that the inventory on hand, and what we knew was available from our distributors, was insufficient. We had to get ahead of this quickly in order to secure the inventory needed to protect Stanford’s workers.”
On Monday, Jan. 27, Stanford placed its first bulk order for N95 masks.
The decision to stockpile was prescient. Prior to the arrival of the new coronavirus that causes COVID-19, Stanford Health Care went through about 640 of the disposable respirators each day, but as COVID-positive patients began to show up at the hospital, that rate increased by more than 600% — to about 4,300 N95 masks per day.
Over the next few weeks, the new coronavirus would strain the limits of not just the supply chain at every level but also the organization’s physical capacity, the dedication and endurance of its workforce, and its ability to safely care for its sickest patients during a global pandemic.
To meet the challenge, clinicians, managers, researchers and staff from across Stanford Medicine — including Stanford Health Care, Stanford Children’s Health, Stanford Health Care – ValleyCare and the School of Medicine — designed diagnostic tests, revamped the flow of patients in its emergency departments, launched drive-through testing clinics and reopened recently decommissioned Stanford Hospital rooms.
They devised models to predict when, where and how urgently infected people were likely to need care, and whether and when hospitals throughout Santa Clara and San Mateo counties were likely to become overwhelmed.
They put in place systems that allowed the organization to quickly cancel elective surgeries, implement telemedicine options for patients sheltering in place, provide testing support to sister organizations, handle tens of thousands of donations of medical equipment and testing supplies, and facilitate an online exchange that allowed Bay Area hospitals to share protective equipment and supplies.
To keep everyone in the hospital safe, they instituted universal masking requirements, symptom checks for employees, a robust testing program for patient-facing workers and policies limiting visitors to the hospital.
And they did it all in an atmosphere of uncertainty and fear and under a shelter-in-place order, which made collaboration difficult.
“In the early days, we didn’t know much about what this disease was or how it was transmitted in all instances,” said Alison Kerr, chief administrative office of clinical operations for Stanford Health Care.
“We didn’t know how best to protect ourselves and our families. Not knowing what to be prepared for is hard. It’s scary. But even though there were so many unknowns, our people came rolling in the door to help. They were running into the fire, rather than away from it. It was incredibly inspirational.”
Lloyd Minor, MD, dean of the Stanford School of Medicine, said, “The responsiveness and dedication of the people of Stanford Medicine in this time of crisis were remarkable. Together, we safely cared for our patients, provided intellectual and material resources to our community, and contributed significantly to the growing body of knowledge about this unprecedented global threat.”
Making preparations for the worst-case scenario
It’s thought that the first human infection with the novel coronavirus occurred around Dec. 1, 2019, in Wuhan, China. The first suspected case of human-to-human transmission likely occurred in mid-December, and by Dec. 29, local hospitals in Wuhan reported the first four cases of a pneumonia of unknown cause. Ten months later, the virus had infected more than 35 million people and killed more than a million worldwide.
The surge in patients that Stanford expected in March and April didn’t materialize, thanks in large part to the shelter-in-place order issued by six Bay Area counties in March to stop the spread of the virus. But in the first weeks of the pandemic, Stanford Health Care had no choice but to prepare for the worst.
“The county asked us to prepare 200 ICU beds for possible COVID patients,” Kerr said. The hospital had 99.
In early January, however, the hospital was in a watch-and-wait mode as it assessed the news from China. The subcommittee on emerging infectious diseases had a regularly scheduled meeting on Jan. 8 in which they discussed the prevalence of what was then known as Wuhan pneumonia. The same day, the U.S. Centers for Disease Control warned physicians to watch for patients with respiratory symptoms who had recently traveled to China.
“I had a very bad feeling about it, even before we really realized it was a pandemic. We were concerned about how a possible shortage of PPE would affect the protection of our health care workers and the care of our patients,” said Sasha Madison, director of infection prevention and control at Stanford Health Care.
“When we first had an inkling that this could be a problem, I had some informal meetings with infection control experts to outline, ‘What are going to be the issues? What is the best way to approach them? What do we do now?’” said Norman Rizk, MD, who recently retired as long-time chief medical officer of Stanford Health Care. “It quickly became evident that we needed a central command system with the authority to make sweeping, rapid decisions about how the hospitals would respond to an increase in cases.”
But how to identify those cases? Many of the symptoms of COVID-19 — cough, fever, sore throat and fatigue — are shared with other respiratory diseases. Benjamin Pinsky, MD, PhD, the director of the Stanford clinical virology laboratory, realized it would be critical to identify and isolate people infected with the novel coronavirus — to prevent further spread and help health care workers decide when it was necessary to use the personal protective equipment that was likely to become in short supply.
When a research group in Berlin published details on Jan. 10 about a diagnostic test they had developed, including critical genetic information about the virus, Pinsky mobilized his team.
“Ben immediately said, ‘We need to get this up and running at Stanford,’” said James Zehnder, MD, professor of pathology and director of clinical pathology at Stanford Health Care. “He had that test ready by the end of January, and we started screening people with respiratory symptoms at Stanford in February.” [Read a separate article on test development at Stanford)
“I don’t know if anyone was completely ready for the magnitude of what was coming. But we had the foresight to do what we needed to do to be prepared,” Pinsky said.
Meanwhile, on Jan. 19, a 35-year-old man walked into an urgent care facility in Snohomish County, Washington, just north of Seattle and explained that he’d been coughing and feverish since returning on Jan. 15 from Wuhan.
And the United States had it first case. Four days later, Wuhan announced its lockdown; on Jan. 30, the World Health Organization declared a global public health emergency. A day later, Santa Clara County, where Stanford is located, reported its first confirmed case in a man who had also recently traveled to Wuhan.
Suddenly, the precautions at Stanford assumed a new urgency. Now it was a race to get ahead of the coming tide of infection.
Critical turning points help lay the response groundwork
Two events were critical to Stanford Health Care being able to prepare for an expected influx of COVID-19 patients. The first was the opening of the new Stanford Hospital in late November, which meant that decommissioned patient rooms in the older hospital were empty and could be tapped for use during the pandemic.
“Our new hospital was the result of more than a decade of hard work and planning, and it enabled us to deliver even more innovative care,” said David Entwistle, president and CEO of Stanford Health Care. “We couldn’t have anticipated what was going to happen just months later, but the opening couldn’t have come at a better time.”
The second was a wide-ranging recall of potentially contaminated surgical gowns in early January — the crisis Chawla was dealing with when Wuhan locked down. In response to the recall, Chawla and her team quickly set up a command center to ensure there were enough gowns to prevent a disruption in surgery schedules.
This recent experience in rapid crisis response, as well as a heightened awareness of the fragility of the world’s supply chain of medical equipment, meant they were primed to tackle this next, even more serious challenge.
“The supply chain is the lifeline and blood of any medical organization,” Chawla said. “We cannot be without the appropriate medical supplies. We started to question the reliability of our suppliers; did they really have the inventory we were going to need?”
Chawla and her colleagues, including Michael Kohler, the administrative director of procurement operations and strategy, started to work backward, sourcing not just the equipment but also the raw materials necessary for their manufacture.
“As we climbed up the pipelines, we could see that, for example, we were likely to see shortages of certain types of plastics or other materials within a few weeks,” Kohler said.
“So we started strategizing how to get ahead of this curve. We were scouring not just international suppliers but also Amazon, Home Depot, any place we could think of that might have things like hand sanitizer, disinfectant wipes and other supplies necessary to keep our health care workers safe. People were working 16 to 18 hours a day seven days a week.”
Despite their efforts, it became apparent that it would be necessary to conserve available protective equipment and explore alternative manufacturing methods for some items.
On Feb. 21, Rizk, Dennis Lund, MD, Stanford Children’s Hospital chief medical officer, and David Svec, MD, the chief medical officer of ValleyCare, launched what is now called the clinical oversight resource team, or CORT. It brought together leaders from across Stanford Medicine involved in, for example, laboratory testing, infection prevention, workforce and supply chain management, and occupational health. On Feb. 28, CORT assembled a PPE conservation task force to explore options and implement guidelines for PPE use at the hospitals.
“All the early information we got about COVID came out of Wuhan,” said Lund. “It was fairly apparent early on that children were less affected. At the same time, we realized the adult facilities might be overwhelmed. So, as we thought about our disaster preparedness, we began to plan how we could best support our adult partners with ventilators, ICU beds and doctors.”
Paul King, president and CEO of Stanford Children’s Hospital, said, “Not all our equipment is sized for adult patients, but we were eager to share what resources we could. We also began to consider reducing the number of elective procedures we performed, in part to conserve PPE if needed for the adult hospital, and we discussed expanding our services to include young adults in order to increase bed capacity in the adult facilities. It was a very collaborative effort.”
Also on Feb. 28, Santa Clara County announced the second known case of community spread of the virus in the United States: an older woman with no history of travel outside the country or previous contact with other confirmed cases. Pinsky’s own surveillance diagnostic test also turned up two positive cases in the third week in February.
On March 6, Stanford Hospital announced it was caring for COVID-19 patients — including a Stanford faculty member in respiratory distress.
“Early in the morning of Friday, March the 6th, I got a call saying that we had a faculty member who had tested positive for COVID-19 and who was going to be admitted to Stanford Hospital,” Minor recalled. “That call really brought it home how serious this disease is. It was a very tangible indication that we were dealing with a serious, highly communicable disease and that we had to do everything we could to respond to the disease and protect our workforce.”
The virus had arrived at Stanford.
Sheltering from the pandemic’s storm
Most people at Stanford Medicine agree that March was a blur as the hospitals ramped up capacity and the medical school turned the force of its research toward understanding more how the virus spreads and how human bodies respond to infection.
Unfortunately, there were few existing guidelines about how best to care for the sickest COVID patients. In response, a group of experts led by Angela Rogers, MD, a pulmonary critical care specialist, formed the Stanford COVID ICU Task Force to assess and compile information from the virus’s early days in China and New York.
Together the multidisciplinary team assembled a set of best-practice recommendations addressing topics as varied as when to ventilate a struggling patient, whether and how to move a patient onto their stomach to aid breathing and circulation — a practice called proning — how to avoid dangerous blood clots caused by the infection, and how to manage a patient’s pain or agitation during treatment. Recommendations were shared in an online living document accessible to other health care workers around the world. [Read a separate article on the ICU team.)
Internists — doctors specializing in the care of a wide variety of medical conditions — were recruited from departments across Stanford Medicine to positions in the emergency department and the ICU to prepare for COVID patients. They and other staff anxiously studied videos showing how to put on and take off PPE safely to avoid contamination.
“In times of crisis, it’s all hands on deck,” Kerr said, “whether the staff were patient facing, or involved in the operations of the organization. Everyone just came together to do whatever they could to try to help. Although people were worried, we all knew you have to just shove those feeling down and get things done.”
One important task was to learn how to care for patients in the emergency department and the ICU while limiting the exposure of health care workers and others to infected patients. To do so, they began to use iPads in the emergency department to evaluate patients from outside the rooms and to connect patients and family members. They also learned how to perform chest X-rays remotely.
“A nurse in the room would position the plate and we could shoot the X-ray from outside the room,” Kerr said. “This is something we’d never tried before, but it worked quite well.”
Efforts to improve patient care also led to an explosion in clinical research studies across Stanford Medicine, many of which were supported by the enterprise strategy team, led by Priya Singh, chief strategy officer and senior associate dean for strategy and communications.
Several researchers participated in multicenter clinical trials of the antiviral drug remdesivir, the use of antibody-rich convalescent plasma from recovered patients and an immune-suppressing monoclonal antibody called tocilizumab.
Other studies included an investigation into the use of self-administered nasal swabs to collect samples for diagnosis, an analysis of the sensitivity and usefulness of pooling samples from several people to conserve testing resources, and assessments of the effectiveness of antiviral treatments known to work for other diseases.
“A lot of really rapid, evidence-based practice has come out of this pandemic,” said Samuel Wald, MD, vice president of surgical services at Stanford Health Care. “Many groups within Stanford Medicine came together to not only solve operational and clinical problems but also to publish their findings.”
As the number of COVID patients in the ICU crept up, however, news about how the situation was unfolding in New York City was on everyone’s mind.
“I was worried we were going to be another Mount Sinai,” Kerr said. “We have a special mission in our community to care for the sickest patients. But the average length of an ICU stay for a COVID patient is about three weeks, which is much longer than normal. We also knew that other hospitals would be looking to send patients to us. One of the real advantages of being at Stanford was the availability of statistical modeling to predict future demand.”
“For the first two or three weeks, it was an adrenaline rush,” he said. “It was like swimming out into Lake Tahoe; you don’t realize how deep it is until you get into it. But we just knew we needed to be compiling some very basic data — case counts, testing rates, and hospitalizations at Stanford and in the surrounding counties — so that senior leadership would have at least a ballpark idea as to the patient load to expect and how much preparation needed to be done. At first, we compiled these data by hand every day.”
This information was relayed to the systems utilization research team headed by clinical associate professor David Scheinker, PhD, who, with associate professor of surgery Kristan Staudenmayer, MD, and professor of medicine Kevin Schulman, MD, used the data to forecast hospitalization trends and bed needs on a hospital as well as county basis.
The scenario the models were predicting was sobering.
“In early March, case counts really started picking up,” Wald said, “and we started talking with leadership about postponing elective surgeries and procedures to create more capacity.”
On Friday, March 13, the possibility became a reality.
“We shut off the elective surgical cases essentially overnight,” Rizk recalled. “In one afternoon, we decided not to do the cases the following morning.”
Any procedure that could be safely postponed for 30 days or more was put on hold. But patients weren’t abandoned. Within days Stanford Health Care was providing 70% of its care via telemedicine — for example, instructing patients virtually how to remove a cast, helping a person check their thyroid for irregularities or reviewing a patient’s medications.
For the children’s hospital, Lund said, the original goal for the year had been to achieve 6,000 telehealth or digital health visits in 2020. “But after we got going we did 6,000 in one week,” he said.
On March 16, six Bay Area counties issued shelter-in-place orders, and normal life for those outside the health care world came to a sudden halt.
Testing ramps up to protect care workers and the public
Not all the news was dire. On Feb. 29, the Food and Drug Administration announced that it was relaxing the restrictions on diagnostic tests for the virus developed by certain high-complexity laboratories, including Stanford’s. Pinsky was ready.
By March 4, Stanford’s test was up and running, making it only the second academic medical center in the country with its own test. Within a week, Stanford was testing hundreds of samples per day from around Northern California — vastly increasing information about the spread of the virus in the surrounding communities and feeding valuable data into the research team’s model of hospital needs.
Around the first of March, Stanford Medicine leaders realized there was another important population to be tested: the hospitals’ staff. Occupational health and safety services had already begun to field an increasing number of calls from worried employees.
“At the time, there was a strong element of fear and anxiety,” Wald said. “People were worried not only about what was likely to happen in the community and the hospital but also about their own health as they cared for COVID patients. Would they be infected; would their family be at risk? Usually our own personal safety is not something we are worried about as health care providers.”
Singh’s team quickly devised a communications strategy, launching a dedicated website and daily email and hosting regular virtual town hall meetings to provide employees the latest information about how Stanford Medicine was handling the crisis and working to protect them.
On March 12, Stanford Medicine launched the Occupational Health Respiratory Evaluation Center and the new Occupational Health Telephone Evaluation Center for employees to receive rapid screening and diagnostic testing, along with advice about how best to protect themselves against infection and when it was safe to return to work after experiencing respiratory symptoms. Stanford Health Care – ValleyCare also offered testing through its occupational health center.
“I don’t think there’s ever been a scenario where you suddenly have to assess the health of your work force all at once,” said Rudy Arthofer, associate chief nursing officer of inpatient access, capacity, and throughput and efficiency.
In mid-April, Stanford Medicine expanded its testing to include all 14,000 patient-facing staff, and by May 4 more than 11,000 employees had been tested. Of those without symptoms, only about 0.3% tested positive, and there were no recorded cases of transmission between health care workers and patients.
“This showed that our PPE guidelines work,” said Rizk. “Our staff are not getting infected by the patients they are caring for.”
An increasing demand for COVID testing in the community and a need to manage the flow of patients within the emergency department sparked the launch of a drive-through screening and testing site on March 15 in the garage outside Stanford Hospital’s emergency department. The drive-through concept was not new; it was first developed at Stanford in 2009 in response to the H1N1 pandemic.
“We set up the garage site within a weekend, including Wi-Fi access, generators, heaters, computers and nurses in full PPE. If someone just needed testing, we could swab them and send them on their way without leaving their car,” Kerr said.
“If they were having other medical problems like a heart attack that needed urgent care, we would bring them in. If they were suspected to have COVID and needed a negative airflow room, we would take them to the side of the building to a different door so they didn’t have to go through the spine of the emergency department and expose other patients or staff.”
Within the larger hospital, others were reconfiguring beds and spaces to accommodate as many COVID patients as possible — a task made significantly easier by the availability of bed space left vacant after the hospital’s new building opened in November 2019. But those rooms had already been stripped of all medical equipment and furniture in preparation for the renovation.
On March 17, the hospital began reinstating these rooms. Lacking time to purchase new equipment, workers had to gather ventilators, beds, cardiac monitors, and even chairs and tables from storage rooms and other areas of the hospital left vacant when elective procedures were canceled. On March 30, the rooms were ready for their first COVID patients.
At the same time, workers devised a plan to increase the number of ICU beds in the new hospital on an as-needed basis.
“The new hospital has an air filtration system that is much more flexible than the older hospital,” Arthofer said. “Our facility team can convert regular pressure rooms in the new hospital to negative pressure rooms within 12-24 hours if necessary. So we could stay two beds ahead in the ICU. When we got to the point when we only had one left, they would covert two more.”
With the bed plan in place and the number of cases rising, the hospital was as ready as possible for the expected surge.
Scrambling to fulfill PPE and testing supply needs
Behind the scenes, supply chain experts Chawla and Kohler were battling increasing scarcity of not just personal protective equipment like N95 masks and specialized powered respirators known as PAPRs and CAPRs but also more mundane items like testing supplies and the swabs used to collect patient samples from the back of the nose and throat.
“At one point, we were down to days or even hours of supply for some items,” Kohler said. “We were literally shuttling certain lab products around by hand from laboratory to laboratory as needed. When we got one covered, we were low on another.”
On March 22, a task force was launched to explore options for 3D printing of swabs, face shields and other items. Soon an ad hoc company created by orthopaedic resident Kim Hall, MD, and a group of Stanford colleagues had designed and printed thousands of face masks. Another local company, Carbon 3D, worked with the group to design, test and validate printed swabs for large scale production by Resolution Medical — answering a nationwide demand for them.
“I’ve never seen a product come to market so quickly, in a matter of weeks rather than months or years,” said Sridhar Seshadri, DBA, chief administrative officer for destination service lines.
“We got out of a very dicey situation where other organizations struggled,” Kohler said.
A call for donations of supplies and equipment by Stanford Health Care president and CEO Entwistle, medical school dean Minor, and Stanford Hospital’s board of directors generated 600 to 800 emails each day from the Stanford community and beyond, sparking the creation of a donation center that accepted about 2.8 million items from around the globe.
“We had to get our own customs broker to facilitate the import of all our international donations,” Chawla said. “We were able to give back to our community, providing equipment to assisted living facilities, and we worked in partnership with a company called Resilinc to create an online exchange market for hospitals in the Bay Area to share and trade medical supplies.”
As the supply chain stabilized, so did the numbers of COVID patients at the hospital — peaking at about 10 to 15 patients per day who needed to be hospitalized. In the last days of March and early April, informatics expert Shah and his colleagues examined each previous days’ numbers with bated breath, looking for evidence of worsening trends.
“In mid-March, it wasn’t clear if we were going to see numbers similar to New York’s,” Shah recalled. “Every morning we’d start with counting the numbers and feeding them into the model. Between about March 18 and March 25, it started to look like it wouldn’t be as bad as we had feared. Every day we’d watch for upticks, but hospitalizations leveled off by early April.”
By mid-April, it seemed the worst had passed. The early shelter-in-place orders in the Bay Area, coupled with social distancing and mask-wearing, had done what they were meant to do: flatten the curve to avoid overwhelming hospitals and health care workers.
On April 14, CORT launched a team to facilitate reopening the hospitals and clinics to more normal operations, which they accomplished with the guidance of Singh’s strategy group.
The strategy group also facilitated the inception of the recover, restore and reopen committee, comprised of more than a dozen experts across the organization. The committee's goal was to address and provide guidance on the many complex issues facing not just Stanford Medicine but also local governments, schools and communities struggling to achieve a “new normal” after the expected surge.
On May 4, after implementing a series of protocols to protect both patients and health care workers, Stanford Medicine resumed elective surgeries.
“Once we felt we met certain safety criteria, we started bringing back interventional care,” Wald said. “We have tested our staff, and any patient who comes to the hospital is tested prior to their appointment. This ensures we are not bringing infected people into the hospital, which protects our staff and our patients.”
Since then, the hospitals have steadily increased the number of procedures, and bed occupancy is up significantly as those who deferred their care return to Stanford Medicine.
“It is both a safe and a smart time to get needed care,” Entwistle said, noting that the organizations have implemented a number of safety procedures and protocols and have tested thousands of patient-facing employees to monitor the health of the workforce. “We’re confident we are providing a safe place for patients to receive their health care.”
The harrowing, frantic days of spring were an important dress rehearsal for what many believe to be the main event yet to come. Infections have risen throughout the country as restrictions on gathering loosened and many people have been less willing than in the early days of the pandemic to take precautions to protect themselves and others.
“Where we are right now is disappointing,” Kerr said. “There’s no other word. There are so many measures that can be taken to limit the spread of this virus: hand washing, masking, social distancing. Science tells us these things work. But, for reasons that are unclear to me, they haven’t been widely adopted.”
But Stanford is ready.
“Now we have testing capacity, we have personal protective equipment and a governance for this situation all in place,” Wald said. “We’re better informed about what constitutes a dangerous exposure and how to limit that for our health care workers. We can be more sophisticated in how we triage patients and be more nuanced in our responses.”
Arthofer agreed: “We know much more than before. We know all the next steps: how to get the beds, how to organize the physician teams, what the options are to handle various scenarios. It will be difficult, but if we had to do this, there is no place I’d rather be.”