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'A profound effect': Cleveland Clinic's Chief of Medical Operations on how Covid-19 is reshaping care delivery

By Taylor Hurst

June 8, 2020

    Cleveland Clinic Chief of Medical Operations Robert Wyllie, MD, recently spoke with Advisory Board's Taylor Hurst and Virginia Hite about the health system's collaborative response to the Covid-19 epidemic and explained why now is not the time to ease up on Covid-19 response plans—or social distancing guidelines.

    Q&As: How top health systems are tackling Covid-19

    Question: Thank you for taking the time to speak with us today, Dr. Wyllie. I wanted to start with a current snapshot of Cleveland Clinic's Covid-19 caseload.

    Robert Wyllie: Of course. As of the end of May, we've had 1,065 Covid-19 hospitalizations, 960 discharges, and 138 fatalities across the system. We've seen the daily inpatient caseload remain fairly stable, hovering between 130-150 cases, since Ohio's peak of about 1,100 admissions on April 22nd.

    Q: How do you think those numbers might change in the coming weeks? Are there any trends you're looking for to identify or mitigate a second surge?

    Wyllie: Like most other health systems, we're keeping an eye on potential hotspots, and we're working very closely with the state government to prevent and predict them, particularly at conjugate care facilities.

    Testing is one component of that. As I mentioned, Covid-19 case numbers are relatively stable right now, but one of the sources we are particularly concerned about is nursing facilities. To that end, we partnered with the state of Ohio to launch a nursing facility testing program in May, starting with the 350 facilities that have had a caregiver or patient test positive. The National Guard has assembled about 16 ten-person teams, medically trained to perform the necessary nasal swab, to go into nursing homes and test employees. We are focused on testing the employees because they are the most likely source of infection for residents.

    We also have geospatial analytics to look at the degree of positive testing. In northern Ohio where all of the Cleveland Clinic hospitals sit, we have the ability to collate and map data from the Clinic and other hospitals and health systems to see if there are clusters that indicate an outbreak.

    Another thing we're looking at is the impact that loosening stay-at-home orders may have on the caseloads. One way we do that is through simulation models. We can see what happens when you lessen stay-at-home to 72%, to 66% to 63%, and the effect it will have on the number of people hospitalized and the number of ventilators being used. In Ohio, staying at home has been very effective in terms of flattening the curve. But once you start bringing people back together a lot depends on whether they continue to follow social distancing guidelines, such as maintaining a six-foot distance, wearing masks, and washing their hands frequently.

    You have heard the, "I protect you, and you protect me," slogan on the news outlets. That is actually true, and it can lead to a substantial decrease in infection rates.

    Q: You brought up a point that I'd like to expand on, which is the level of collaboration that has taken place in your market. How has that collaboration evolved, and what are the steps you're taking to stay nimble in case of a second surge?

    Wyllie: Yes. Ohio did something interesting at the start of the epidemic. The state was divided into eight regions and then collapsed into three zones, each with an appointed zone leader. I am the lead for Zone One, which is northern Ohio.

    Rather than coordinate the medical response strictly among the Cleveland Clinic health system, we were tasked with working across our zones to coordinate our response between all of the local hospitals, health departments, and other facilities, such as nursing homes, correctional institutions, etc.

    How hospitals are forging nontraditional partnerships amid Covid-19—and beyond

    We have calls almost daily with our other health systems and at least twice a week with all of the hospitals and other health care players in the northern zone. During these calls, we see how many Covid-19 patients they have, what their stressors are, how they're doing with PPE, and if anyone is aware of a new outbreak.

    This collaboration has enabled us to manage daily outbreaks. For instance, when the health and federal penitentiary in the eastern part of Zone One had an outbreak they began transporting patients to local hospitals, which quickly became overwhelmed. As a zone, we pooled our resources to create a triage system for positive inmates with two rungs: first, we sent the patients to hospitals in Akron, but if they were at capacity, we transported the patients to Cleveland. There was an understanding that if we work together, we can prevent any single facility from being overwhelmed and ensure that each patient gets appropriate care. And it’s is working pretty well right now from my point of view. 

    Q: I'm curious, as the Covid-19 cases level off in the state, how do you see that level of collaboration evolving? Are you beginning to have conversations about winding things down or changing the cadence?

    Wyllie: We're definitely evolving in terms of the questions we're considering, but I don't expect those weekly cross-system meetings to stop anytime soon. The threat of Covid-19 won't significantly lessen until, and unless, we develop a vaccine. In the meantime, we're thinking through the impact of the physical distancing experiment as more businesses reopen and what we're going to do with schools next fall. Ohio State, which is in Zone Two, is one of the largest universities in the United States. They have 105,000 students potentially coming back. So, we need to consider: What do you do with those folks? Who do you test? Are you going to test everybody?

    The other thing we're preparing for is the next influenza season and how we can manage those patients' respiratory difficulties. Even if Covid-19 infection rates stay stable, it is going to have a huge additive effect on health system strain as we start to see influenza cases. We still have to figure out—not just the Cleveland Clinic but all of the other systems in the area—how we are going to manage an influx of influenza patients? What does that look like? How do we prepare? We can’t really celebrate having a handle on the PPE challenge today because we will potentially need twice as much as influenza starts presenting in the fall.

    Q: It sounds like you'll be working closely across your zone for the foreseeable future, and that the level of collaboration has largely been effective. What advice would you offer other organizations that want to establish stronger or more effective partnerships with others in their community?  

    Wyllie: You have to be proactive. I think that for large academic medical centers like the Cleveland Clinic, we had to go out and embrace the local health departments. We found out what they were doing, what they needed, and how we could be of assistance.

    From there, we looked at how we were going to approach and support groups that are at greatest risk:  congregate living facilities, minority groups, and federally qualified health centers. For example, we have four poultry processing plants in the southern part of Zone One that are staffed by a largely Guatemalan population. We partnered with the local health department to identify the appropriate people to serve as translators—not only to ensure the employees got the right health information, but also that it came from a trusted member of their community. We also continue to ask how we can be of use to the other systems and support their efforts to make sure we can take care of the broader community.

    In short, consistently ask what you can you do to support, and consider the resources you can uniquely bring to the table to help your community

    Q:  We’ve talked about some of the ways Covid-19 is changing Cleveland Clinic’s operations and partnerships. When we take a step back, what do you think will be the biggest changes to health care resulting from Covid-19?

    Wyllie: I think this is going to have a profound effect on the medical delivery system. I do think this new level of coordination we're seeing in Ohio is here to stay. You'll increasingly see large academic medical centers, and the large medical centers, working to fine-tune their relationships with local health departments.

    Another thing that I don’t think is going to go away is telehealth. At Cleveland Clinic, we went from 5,000 telehealth visits per month to 200,000 in one month. Telehealth adoption in the United States was moving very slowly, and then all of a sudden Covid-19 came along and forced a lot of people to make the switch. It not only taught doctors that they could do telehealth effectively, but it also taught patients that you don’t always have to go in to get care, particularly for chronic disease management. If you have a problem with hypertension or diabetes a lot of that can be managed with a telehealth visit. I don’t think that is going to change. I think that the shift toward virtual care is going to be permanent.

    One challenge for the health system going forward will be convincing patients who have deferred health care that it's safe to return to the hospital, and addressing the rising number of high acuity patients. I had a call last week with other hospital leaders and every single one noted that their ED patients are presenting with more advanced illness. We have to get back to more proactive diagnosis, but that is dependent on patients knowing the hospital is safe and not a place where they have to worry about catching Covid-19. There is a greater risk of infection in the community than there is in the hospital. And I think we still have some work to do about getting that message out.

    But in the meantime, I think the medical community needs to remain vigilant. Everyone needs to stand together and encourage the public to wear a mask, keep social distancing, and wash their hands. With or without testing, we can still affect the rate of infection if we are willing to do those things.

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