SPEAKER 1: Hello everyone. Thank you and welcome to a Medical Grand Rounds. This is a really special week for us. We have Dr. Anthony Fauci here on Wednesday who really talked about the COVID-19 pandemic on the national scale. And then we're really privileged today to have Dr. Enfield here to really talk about the impact of the pandemic on the UVA community and some of the great innovations that have happened right here on our campus. 

So a little bit about Dr. Enfield. I'm sure many of you know him, but he is the director of our Medical Intensive Care unit and he has really been in the trenches of this pandemic since the beginning. He's often been on service as the attending on the Special Pathogens Intensive Care unit, as well as the friendly voice behind the hospital epidemiology phone. He has helped many of us figure out who should be tested, especially when we didn't have as many tests available. So we really couldn't have done any of this without him. 

A little bit about him. He actually has done his internal medicine training here at the University of Virginia as well as his MICU training. And then we were really lucky for him to stay on here as faculty. And we're even luckier today for him to give us this presentation of not only how COVID-19 has impacted the Charlottesville community but also how it has impacted us as health care workers and where we can go going forward. So without further ado, here is Dr. Kyle Enfield. 

[APPLAUSE] 

KYLE ENFIELD: Thank you. That was a very nice introduction. I really appreciate the friendly voice at the end of the hospital [INAUDIBLE] pager. I am pretty sure that there are some people who have not thought my voice was so friendly when I was talking to them this last week. 

I can't help but say I wanted to thank Dr. Fauci for being the opening act for me today. You know, it's a little bit like having the Mormon Tabernacle Choir open for my high school choir in 1992. We were good enough to win nationals that year and we sang Ave Maria on the stage of the Grand Ole Opry. So we're good. But not quite the Mormon Tabernacle Choir. But luckily, Dr. Fauci and I do have the same COVID-19 mask from the Society of Critical Care Medicine, so I might be able to reach close to the standards that he sets. And it is a lot of fun to talk in the same week as someone who I consider a hero for our country, and for the world, and trying to deal with this pandemic. 

When I agreed to do this, I spent a lot of time thinking about what is it that I could say different than what Dr. Fauci would say. Obviously, he is an expert in infectious diseases. He has been in the forefront of thinking about this deeply for a long period of time. And what was it that I would bring different to you that would be insightful and useful? 

And one of the things that I really wanted to be able to then do is tell stories. And tell the story of the people that have been working in the Special Pathogens unit that we may not always hear. Talk about their hopes, their dreams, their concerns, their challenges and weave that into what we've done here at UVA. 

Stories are really important in all cultures. The Lakota people of North America talk about this time of year being important for telling stories so that we can remind ourselves of where we've come from and where we're going. The Lakota elder Black Elk said when he was asked to do an autobiography "My friend, I'm going to tell you the story of my life as you wish; and if it were only the story of my life, I would not tell it. For what is one man that he should make much of his winters, even when they bend him like a heavy snow. 

COVID has impacted all of us like a long winter. We have been isolated from each other, we have been challenged with testing and PPE. The loss of friendships and the loss of traditions. The lost ability to together with grand rounds without mask on. And so these are our stories and our stories are uniquely different than the stories that will be told in Washington DC. It will be different than the stories that are told in Chicago, and in New York City, and in Atlanta, and in California. But there still are stories and so they are important. 

And I think it's important for us to realize that we shouldn't minimize anything that we have learned and we should celebrate all of our successes. So with that in mind, I want to take you back to February 25th when Costi Sifri and I both shaved off our beards because we knew that a pandemic was coming. And we knew that we'd all need to be wearing N95 masks soon. And I say that with a little bit of humor because it's probably the only picture you'll see with no mask on today. With both of us smiling. And I don't think either one of us smile as much anymore. 

And we're really try to cover three things. We're going to talk about local epidemiology compares to national and try to drive home some points about the global and national impact of this disease. I'm going to have been a good bit of time talking about the UVA experience, what we have learned, what we've contributed. And then I want to talk specifically about the care providers in the Special Pathogens unit and what their experience has been. 

I've been really privileged to be given I feel like hundreds of photos now from nurses and respiratory therapists and I'm going to share a few of those. I censored a few of them. I've also collected a lot of stories and comments, which I'm going to anonymize, because some of them are going to be a little painful to hear for some people. But I think they're really important to reflect on where we've come. And I've tried to weave these stories in throughout the presentation so that we can really experience them together. 

So where we've been. And I want to start with a comment from one of our providers who's a nurse in the Special Pathogens unit who, when I ask her what really makes you angry, it was this. "I'm upset when people on the sidelines debate masks or the validity of ventilators or lock downs as if they've ever looked at a patient in severe respiratory failure. They don't do what we do or see what we see. People can talk all they want to and discuss the stats like it's a high school debate team. But at the end of the day, those numbers are people. That small percentage of mortality are the patients I take care of. And they had names, lives, and families. 

So when we talk about the epidemiology disease, we need to remember that these are people that had families that missed them. And we're not doing well, especially in the United States. I chose these three countries. This is data that you can access from Our World and Data. It's a great website if you want to get figures from our talk ever. They have lots of cool stuff in there. 

But this is standardized case rates per million people. And I chose a couple of countries. I chose the United States, obviously, because that's where we're talking from. I chose Sweden because they had a very different approach to COVID-19 isolation than anybody else. I'm not going to go into the weeds of it, but I actually talked to one of the guys who did their modeling and listened to some of his regrets and thoughts on it. And afterwards, I'm happy to share those with you. 

I talked to him because he happens to be the colleague of my father, who did a lot of modeling in his day. And so it's a good friend of mine. So I respect him. He's also a little bit insane 

I also chose Canada, Japan, and New Zealand because they had very different approaches to how we would handle the public health crisis that was this pandemic. And as you can see, the United States is really leading the edge of new daily confirmed cases. We heard this on Wednesday. Over 150,000 new cases per day. That's gone up since then. I think it was around 176,000 yesterday. We're on track to break all sorts of records and I'm not sure that that's really the place that we want to be. 

The United Kingdom is not doing so great behind us and Sweden is really struggling. As compared to that, New Zealand has been doing great for a long time. And obviously they live on their own country. They're an island. They have a lot of different resources. But they've been able to really control their experience. So is Japan. 

When you look at deaths per million people, the United Kingdom is excelling in that area, though we're not too far behind. And one way to look at this is to think about how the country's rate of new disease versus the deaths of those people. This is a logarithmic scale. And you can see that while we all had very similar death rates. And one of the things that has defined the differences between these countries has been the ability to control their disease by limiting new infections. 

A lot has been made out of the fact by some people about maybe the lock downs aren't good. Maybe this doesn't control death rate. Maybe if you standardize versus flu years before that maybe the death rate is not as bad as we think it is. But if you look at the raw numbers, internationally, 57 million cases of COVID-19 have occurred, of which 1.3 million people have died. 250,000 of those deaths in the United States. 

Just so you guys can have a little bit of reference for that. Between 1965 and 1974 during the Vietnam War, 282,000 Americans lost their lives. So in nine months, we're going to beat the Vietnam War. In 1918, over 600,000 people died from influenza. We didn't have ventilators then. And so we're not succeeding. And if you just look at all cause mortality on a weekly basis, and you look from the years 2015 to 2017, and compared to 2020. Even if we've been mis-attributing deaths as some people have said, who will remain nameless, we are still dying at a higher rate this year, in this country, than we have for the last five years. 

That is really unacceptable from a public health standpoint. And I think that we've heard it once but we should hear it over and over again. Not all populations have been equally affected by this death rates. Systemic racism has led to the deaths of minority communities at a much higher rate than white communities. And that is a problem that we are going to need to address at a public level for a long time to come. 

So how are we doing in the state of Virginia? And this is- John Voss pulled this data for me and I'm really appreciative. He actually gave me several graphs that we're going to go over in the next few minutes. It really looked at pulling the data from the New York Times GitHub repository on the 16th. And what you can see here is that we have begun- oops I'm using the wrong button there. We have begun to- that is it? 

we've begun to really increase the number of cases that we're seeing in Virginia all the way around. Though our mortality seems to be lagging behind, and maybe it's flat. I would tell you that what you see here will be followed here in a matter of days to weeks. Maybe longer than that. 

It's hard to think about the whole state of Virginia because that's really been regionally different. And if you look at the state of Virginia, what you'll see is that in southwest Virginia, we've had areas of extremely high growth. This is included in Roanoke as well. 

In northern Virginia, recently, we've seen less growth. But that is starting to accelerate. And if you really look at the case rate per 100,000 population, Albemarle County has been this donut hole in the middle of an expanding epidemic. And maybe that's because we're better at wearing masks here. Or maybe it's just because we've been lucky. But that luck may be changing soon as we know that Augusta Health is seeing more and more patients recently. Culpeper are seeing more and more patients. And we know that the rates of disease are increasing in our county as well. 

If you look at the state of Virginia, and you look at minority populations- and this is a little bit hard to see- but those green lines of the Latinx community in our area. And this is a standardized attack rates per 100,000. And this is a cumulative attack rate. So not- you'll see that the Latinx community, the black community, have been disproportionately affected over the white communities around the state. There's some regional differences, but this is something that has occurred globally around the state and is not isolated to one place or another. 

We have been fortunate in the Thomas Jefferson Health [INAUDIBLE]. This is the replication time for COVID-19 within the Thomas Jefferson Health District. You can see the last couple of months, we've had a replication time of less than one. There's probably a lot of factors that go into this. I bring this up because it was very controversial for us to open up UVA this fall. There is a lot of things on Twitter that were pretty negative about that. There are a lot of things and other social media posts about that. 

But what was the impact of the university community? This is actually a hot topic around the world because people want to know, is it safe for universities to come back? And every university is probably unique. But at least in Charlottesville, we don't see a huge impact from the university students coming back. 

So the red line in this graph is a smooth line of new cases per day in the Thomas Jefferson Health District if you exclude students. The blue line is the Thomas Jefferson Health District including students. And what you can see is that we did have a significant increase in positivity in the whole health district early on as we saw the increase in rates of disease within the university. But that was not followed by a significant uptick within the Charlottesville or the Thomas Jefferson Health District of other community members getting sick. 

So for reasons that may not be fully explained until much further along, it seems that we did a fairly reasonable job of controlling the spread of disease from the university to the community. And whether that was because the students were very good about wearing masks, or whether that's because there is actually fewer interactions between students and the rest of the community is something that we'll have to debate in the future. But at least this Fall, we've done well. 

It should be mentioned that when we talk about this, that there is at least 40% of cases that are asymptomatic and may not be tested. And so we're probably missing a portion of the iceberg that is COVID-19. There's probably some people that have mild to moderate system that stay home that don't get tested because they don't think they're that sick, and so we're maybe missing those. 

And oftentimes we're really looking at the 12% of cases. How do I get to 12%? I took the 60% of people that are symptomatic and multiply it by the 20% of people that get hospitalized and got to those numbers. But the 12% of cases that come into the hospital, 3% of which are critically ill. 

What's important about those asymptomatic cases is there's a [INAUDIBLE] study that came out in July 28th of this year that showed that probably 50% of transmission occurs from asymptomatic individuals. And we have a large challenge in addressing that. And we're going to talk a little bit about how that's affected our hospital in a few minutes. 

So what do we anticipate happening with COVID-19 here in Charlottesville? I really wish I could tell you because predicting a pandemic has not been as easy as it was to poll for the US election. And we saw how well that turned out, for polling anyway. It hasn't been as easy as it is to predict the weather, which is only good for about three days in advance. There have been really smart people, and they've done very well, but we can probably predict one to two days in advance. Maybe a week in advance. But further out, we don't really know the trajectory because there's so many factors that could influence it. 

Do people travel for Thanksgiving? Do people interact with each other more than they have? Do we get tired of isolating from each other? Do we get tired of social distancing? Do we stop- do people get forgetful about wearing their mask when they're in the hospital and they're having a joint meal in the break room? All these things become important. 

So the things that we don't know really reflect the fact that we don't have a national strategy for the public health measures necessary to control COVID-19. And if we don't call that out more than once, we're really not doing our job. 

So what is it to live and die with COVID or SARS-COV2? If you go up onto 4 South and you face this direction, you might find a room with red post-it notes in the shape of a heart on a window. Those post-it notes are put there by our nurses so that the family members- you cannot visit those patients who are sitting on top of the parking deck right now- can see where their loved ones are. 

Kendall Barger will not mind me saying this, but she wrote in her journal a few months ago "It's the weekend. My stomach hurts. Your husband, he's back. He's parked in the spot directly across from your window. He calls and talks to you, even though you haven't responded in weeks. He sleeps in his car across the window whispering his love to empty seats. It's almost your anniversary." 

This is a daily occurrence for the nurses and respiratory therapists, and others who work in our 4 South and 5 South tower. Family members who can't visit their loved ones who want to. By definition, intensive care is the application of resources in the hopes of returning a person to normal functions. But the critical word in this is care. And that is what the team in those units has really accelerated and accentuated this year. 

And it's not just the doctors and the nurses. It's also the hucks and the EVS staff, who I didn't get to interview and I regret, the pharmacists, and a whole host of people who really make those units work. They make it work for the 538 lives that have come through UVA. 

I really hope this slide advances. There it goes. And these are just a few of them. If you go into 4 South today, you can walk through and you can see our wall of COVID survivors. These are just a few of the people who have come back to our COVID clinic and have been seen. We're going to talk a little bit about their outcomes in just a minute. But I will tell you that these pictures actually provide a lot of hope to many of our nurses and nurse practitioners who work in that unit. It brings joy to see these successes. 

Our local outcomes have been fairly decent. What I've seen is that the majority of our patients have survived. We have had mortalities throughout the year. It's higher in those patients who require ventilation, so about a 36% rate of mortality for patients who require mechanical ventilation. About an 18% mortality for ICU care without mechanical ventilation. And a fairly small number of mortalities in the acute care population that don't require ICU level care. 

These rates are fairly comparable to other academic medical centers. And it's a point that I want to drive home is that academic medical centers have done better overall than community hospitals in the care of patients with COVID, and there's a lot of reasons that we can talk about that. If you look across the state, you'll see that UVA has cared for patients all around our state, North Virginia- North Virginia- Northern Virginia, North Carolina, and West Virginia. 

We've had patients that have been infants, all the way to a woman who was 106 years old who survived COVID. That means she survived five pandemics and two world wars. We are trying to run her DNA sequencing so we can figure out why. She, unfortunately, did not consent to that and she was compis mentis. 

So we've been trying to find out what happens to these patients because we know that COVID has significant impacts. A peer of mine, and a colleague, Holly Prescott, who works at the University of Michigan, has actually been sampling all patients with COVID who were hospitalized. And it's found that there's a significant amount of depression and mental health challenges following COVID care. 

At UVA, we've seen 56 of our patients who required post ICU, who were in the ICU who came to our post ICU clinic. 68% of them have had delirium during their hospital stay. Of the patients that we have seen who have come back, so we get into some sampling errors here, of those who are previously employed, only 24% of them have been able to go back to work. And 70% of them have signs of cognitive impairment, as measured by a MOCA score of less than 26. If you're not familiar with the MOCA score, it was widely popularized by CNN a few years ago. Somebody may have had a test on it and did really well on it. Outstanding, in fact. 

We published these results. And I just I have to acknowledge that Chintan Ramani, who is one of our PGY three- PGY six Fellows in pulmonary critical care. This has been something that he was passionate about. He got started. He has seen every single one of these patients. Done all this testing on pieces of paper. Collated it. 

He and Alex Kadl really led this charge. They published the first 30 of these patients in an article in chest in August of 2020. And it led to us being invited to be part of a group called the Oracle group, which is made up of hospitals that have ECMO and post ICU discharge clinics. It's a very small group. Falls, University of Colorado, Hopkins, University of Kentucky Vanderbilt, and us. 

And what we really want to know is of patients who come into the hospital that require ICU care and compare those who recover with COVID, those who received ECMO versus those who don't. Because we're throwing a lot of resources because we believe ECMO will work to help stabilize patients to have organ failure. But we need to know if those patients recover. Because we're not just trying to get people to survive anymore. We want them to thrive when they leave the hospital. We don't know if they are going to be a person who thrives or a person who has disability. And if we can figure out how to predict that, we will do a better job. 

This is just one picture of one of our ECMO patients. This is actually one of our current ECMO patients. Through the looking glass as I like to say it. You can see that this is intensive care. This is a lot of resources to get people to survive. And we don't know. We've only really been dealing with COVID for around 10 months. We don't know the outcomes of these patients. 

We recently had a patient. And one of the nurses told me this story. She said we had a patient had been ECMO for a long time. It was one of the sickest patients he'd seen. They'd weaned sedation off. They decannulated it and the patient was not waking up. It was a young man. He was completely unresponsive to all stimulus. And the care team, the ECMO providers, including the thoracic surgeons to some degree, the respiratory therapist, the nurses really felt that what we needed to do is begin to have goals of care discussion. Because in most ECMO patients, this would be considered someone who is not going to wake up. 

But recognizing that we didn't know, Dr. Barrows gave him the extra time he needed. And at a 12:00 PM neuro assessment, the nurse asked the patient to wiggle his toes, and he started to. And she remembers calling through the iPad and into the charge nurse vocera screaming out "He's awake. He's awake!" And a few weeks later, that patient walked out of the hospital. We've got a lot to learn and there's really no way to overemphasize that. 

We had a lot to learn about testing when it first came out. In the Spring of 2020, when we started this PIC group 9204, which is made up of a lot of people that you've heard of before. But these can be difficult calls. The Spring of 2020, we didn't have enough NP swabs, we didn't have enough testing, and we really had to do a lot of innovation. That innovation has been led by Mindy Poulter and Amy Mathers and many other people. And I'm going to talk about one of the things that they've innovated on that you hopefully know about, but may not. 

By Summer, we had more platforms. We had begun testing wastewater, which is a near and dear thing to my heart. And now we have multiple testing platforms. We have rapid symptomatic testing, priority asymptomatic emission testing, which we'll talk about in a second. And then routine testing, which takes about 24 hours for the outpatients and everything else. 

One of the things that I highlighted is the fact that we didn't have enough NP swabs. But anybody who's knows Amy Mathers knows that she's not daunted by a problem. And working with biomedical engineering, they developed their own supply of NP swabs. So we went from 3D printing to injection molding. And we were able to- she was able to. We is the wrong word. She and her team were able to develop an NP swab that passed a clinical trial that now has FDA clearance and is being distributed across the states. 

They produce 75,000 swabs per week, of which 60,000 go around the state to allow for testing, and of which we use 15,000 at the UVA. This is really a UVA project, but just so you know that the injection molding is actually done in Minnesota. The flocking, which I do not understand but is very important to get the little fibers on there correct, is done in Indiana. And the quality check and packaging is done at Richmond. But the FDA holds us responsible for the outcomes. This is pretty cool stuff, to think that we went from having done enough swabs because you couldn't buy them to producing our own. 

There's been a lot of work in therapeutics because, if you remember back to March and you asked me what do you do for COVID care, I said really good critical care because that's all we had. This is a picture from our 5 South team who has been really forefront in helping and recruit patients for clinical trials. Because in March, what we said is what people needed to do is be involved in clinical trials because that's how we're going to learn. And UVA has been very good at recruiting to clinical trials. 

We've had about 143 of the 538 patients we've seen. 143 of them have been appropriate for clinical trial enrollment, which 27% did enroll. Which is a pretty decent enrollment rate. We opened our first clinical trial, which was the Act One trial, which is what led to Remdesivir getting an emergency use authorization from the FDA 10 days after our first patient was admitted with COVID-19 to the University of Virginia. 

And part of this is because, early on, the health system and the School of Medicine realized that we needed a way to prioritize COVID-19 trials. What we didn't want to have happen is every investigator opening their own trial, going through the standard process to opening, and then competing with each other. There's not going to be enough patients at UVA for us to have 4,000 randomized controlled trials going on. 

So Linda Duska, who is the associate dean for clinical research, formed a committee called the COVID Clinical Research Prioritization committee. It meets weekly. We review all the trials that are being proposed to take on and then we prioritize them. This has not been a perfect process. We've probably rejected some trials that we maybe shouldn't have. But it has been very successful in that, on average, within a week of an investigator submitting their trial, we've told them if their trial can move forward or not. And IRB approval is, on average, about 27 days. I probably should have given the median because the median is much lower. And that's a significant improvement over traditional clinical trials results. 

That group, and the clinical research coordinators who have really run these trials, has also been successful in doing something else. And that is recruiting patients to those clinical trials that match the patients that we are seeing in the hospital. It hasn't been perfect, but it's been better than our UVA historical trial participation. So for the Black population, which has made up 26% of the cases at UVA, they've made up 17% of the research participants. Traditionally UVA gets about 10% of its research participants from the Black community. 

The Hispanic population, which has made up 23% of our cases, has made up 23% of our research participation. Traditionally, 2%. This has really been because the clinical research coordinators have been thoughtful about what they've been doing. 

We're still trying to understand why we've been successful in doing this, but it is a historic change in how we've done before. And I think there's a lot of people that will not go recognized. And I wish I could remember all the names but Miranda West and China Green, who have been our lead CRCs for many of our trials, should get a huge thank you from all of us. Because without them, none of this would've been possible. 

Because that's really allowed us to participate in a lot of great trials. So current therapeutic considerations, this is published by Patrick Jackson and the ID group of what should be recommended and what should be considered and not recommended. I'm going to call out two of those, and that's convalescent plasma, which we have done some specific work here at UVA from, and Remdesivir. I will tell you that these guidelines are pretty concordant with what the NIH publishes on their COVID-19 treatment guidelines. Which, if you are doing COVID care, you should look at. It's a really nice resource with lots of references. 

ACTT-1, you may be familiar with, randomized 1,062 patients to receive Remdesivir versus not receiving Remdesivir. We enrolled our first patient, like I said, 10 days after- we enrolled our first patient in the ACTT-1 trial 10 days after our first patient was admitted. We had a reasonable participation in ACTT-1, a much better participation in ACTT-2 and ACTT-3, which I'm not going to go into a lot today. 

What ACTT-1 demonstrated was that patients who receive from Remdesivir had, on average, a quicker recovery than those who did not. Now, many of you who are astute will say, well the World Health Organization just released that they do not recommend Remdesivir. They had a open label trial that showed no difference between groups. It's really very difficult to compare these two trials. And I think that locally, and at least nationally, we still believe that there's a strong role for Remdesivir in patients that are not requiring mechanical ventilation. 

The other thing that we learned very early on, thanks to the recovery trial, which is a European Union trial, was dexamethasone for patients who required oxygen was lifesaving. And this is a change in the way we think. Because for influenza, we typically do not recommend steroids because we know it prolongs viral shedding. It prolongs viral shedding in COVID as well. But what we do know is that the patients have a survival benefit if they get it. 

Convalescent plasma has an emergency use authorization. The CIP-T trial- which the data for I begged for, but they did not release it to me, which is probably appropriate- was a UVA-instigated and funded trial that was led by Jeff Sturek. What's really remarkable about this trial is that the study team started meeting on April 7th. And they completed their enrollment and began their analysis on August 16. So within around four months, they had gone from study idea to study completion. 

And for those of you who have done clinical research, you know that that is a really amazing turnaround for any project. And I really want to highlight, again, that this is because of the fabulous work of the clinical research coordinators, the COVID prioritization committee, because they were able to move things quickly. And align the IRB, the grants and contracts office, everything to make this happen. But a huge shout out to Jeff and all of his colleagues who participated in this research. It has been really amazing. 

In the 244 days that we've been caring for patients with COVID, we've learned a lot of other things that I'm not going to go into all these. I'm going to highlight two. First of all, I often get asked about Vitamin C. For those of you who've never heard me present on grand rounds, there is no clinical evidence anywhere that vitamin C helps in hospitalized patients regardless of the condition. It is very expensive to give IV, and most of it comes out in their urine. There are still ongoing clinical trials, and Paul Merick, if he's listening today, will probably write me a very nasty email about this. 

The other one that I will highlight is tociluzumab for the NIH standards, has been recommended against. I want to comment only that yesterday afternoon, in the lowest form of scientific publication that is Twitter, the recovery trial announced that they had stopped the toci arm of their recovery trial. For not for futility, but for benefit. However, the clinical trial has not been released or published, and so we don't really know what that benefit is and/or who benefits from it. So at this point in time, there's really- we do have toci available at UVA and its use on a case by case basis, usually after a multi-disciplinary meeting between ID, pulmonary critical care, and hematology. 

There are a lot of ongoing clinical trials, still, and more opening. In the last week, the prioritization committee has received five emails for new clinical trials. We'll probably be able to open one or two of those up. ACT still, is ongoing. There's ACT four and 5 coming. Patrick Jackson is the site PI for that and will continue to push that forward. There's a mesenchymal stem cell trial from the NIH that Jeff Sturek is leading. They've had a pretty decent enrollment, but not perfect. 

ACTVV- and I'm sorry, I did not come up with these names. I do not know why one got to be ACT and one got to be ACTVV. Patrick Jackson will point out that ACT came first, and therefore they get to naming rights, but that we're stuck with it. ACTVV. The next clinical trial is ACTVV four, which is going to be looking at anticoagulation and COVID disease. And we know that that's been a hot topic for trying to figure out. And then Regeneron, which I think everyone is familiar with, has an ongoing study that UVA has been a lead recruiter for, looking at the administration of Regeneron to patients exposed to COVID and for prevention. I still think Regeneron, regardless of who you are, should be given as part of a clinical trial. But we'll go into that later. 

We've learned a lot of other things too. When we first started COVID care, we said that non-invasive ventilization of patients should not be done. We're either going to intubate them or use a high flow. We now know, from international experience, that non-invasive ventilation is probably safe for these patients and probably should still be used. And probably is helpful, particularly in the acute care setting, where we have patients have obstructive sleep apnea. My shout out to Dr. Davis is in the room with me today. Really should still get their CPAP at night. We shouldn't be withholding that for them. 

The role for anticoagulation is unknown. There's future trials for this and we're still learning about ECMO and extracorporeal CO2 removal in these patients. So we need to know more. But I can't leave talking about our treatment outcomes without highlighting the work of our transplant team, who transplanted probably one of the half dozen people who receive lung transplantation for COVID-19 disease in the world. 

This patient was diagnosed on August 25th with COVID. Is transferred to UVA a month later on ECMO. Was weaned from ECMO, but then ended up being intubated. However, on October 13th, he received his lung transplant. About a week later, he recovered renal function and has been off dialysis since. Day after that, his tracheostomy was removed to room air. He left on the day before Halloween for acute inpatient rehab. And on November 17th, he returned home and is doing very well. And so if you see Mark Roser or Hannah Manham or Max Weider, or any of their nurse practitioners, please congratulate them on that success. 

We have a lot that we still need to learn, but outpatient treatment- I can never say the mab names- but has recently been approved for COVID treatment in the outpatient setting. The COVID clinic. I just got off the phone, right before this meeting, with Arch Sevroda, and we will be able to administer infusions in the COVID clinic at UVA starting, hopefully, the Monday after Thanksgiving where we will also be able to open outpatient clinical trials as necessary. So we are going to be able to provide all the care we need for our patients. There are only 26 doses coming to UVA and Patrick Jackson has a meeting this afternoon about how we're going to utilize those to the biggest benefit of our patients. 

I think we have to acknowledge that our experience has not been the experience of others. Many of you know Jeff Young. He is on a national disaster relief. He's been to El Paso, Texas and El Centro, California supporting them. And he told me "I think the patients I dealt with in both places did so poorly because there was no continuity or plan through the phases of care. They were moved from the ED to the floor to the ICU, and whoever is working in that area that day started from scratch. I believe they would have had more success with a small group of knowledgeable people supervising the care of COVID positive patients throughout the spectrum. But of course, I have no evidence that would support that would have worked." 

There is evidence that this works. If you compare small community hospitals to larger academic medical centers for outcomes related to COVID care, there is a three-fold increased risk of death in the smaller hospital. It translates to a number needed to treat, if you really look at the extreme outliers, of three for moving someone from Bath County to UVA for their COVID care. 

We don't do that systematically, though. It's by chance. They call at the right day, we have beds available. And so patients are going to get systematically different treatment because they don't have the facilities to care for them where they need them. These things cost money as well. It is hard to do COVID care and we're going to talk about that now. 

But there's an impact on our team, and there's an impact to costs, and we have to think as an academic medical center how we prioritize our beds as we move forward. This is a very crude estimate that on 4 South and 5 South, and 3 South before that, and the MICU in 3 West before that, over 180,000 hours of care have been provided by physical therapists, respiratory therapists, nurses, and LIPs. 

It's a big number for 244 days. It's a lot of manpower to take care of these patients. And there's some strain with them. "They're glass walls, the COVID rooms. Glass is supposed to be transparent. Full view, continuous visual access to another place. But it's firm and solid, and while you think you can see it all, you can neither touch, feel, or experience. Separation inside glass walls, you can be partially seen and so very alone. 

That's the lived experience for many of the people who work in the COVID unit all the time. They also remember that on April 16th, we were waved on as heroes. But we can't escape it. All of a sudden, everyone has an opinion about something that you're considered an expert in. At first, we were called health care heroes. And now we're told we're part of a hoax, and we should have just opened our eyes to the truth. I have family members who told me I was a shady liar, plus a few other choice words I'll leave out here, when I expressed my concerns about COVID after being part of the fight. 

While we can insulate ourselves within our walls and talk to each other about and support each other, many of our providers go home to families who do not support them. Some of you may have that same experience. That you have a loved one who doesn't really understand COVID and thinks that it's all part of a hoax. That these wearing of masks, that's futile. 

180,000 hours is just an estimate. It's really hard to get exact numbers. Rob Kelleher said "COVID uprooted the MICU and NP practice. We have focused solely on COVID patients. I have worked in the ICU-SPU since the beginning. I admitted the first COVID patient to 3 South and treated COVID patients in MICU west. These patients shouldn't receive- should receive, sorry. These patients should receive the same care as anyone else with some consideration regarding safety and isolation precautions." 

8,784 hours is what the nurse practitioners in the MICU have given to COVID care. They have not had one day outside of 4 South, 3 South, or the MICU with COVID patients since the beginning- since middle March. Most of us get lucky. We get to see other patients in other areas, but all they do is COVID care. Day in and day out. The remarkable thing in 8,764 hours, they've had no exposures, no illnesses, and no acquisition of disease. 

The demands of COVID care have been difficult. In a self-reported question about emotional health to our providers in 4 South and 5 South, nurses in general rate their emotional health much worse than LIPs. And LIPs includes nurse practitioners and physicians. Though in general, they rate their physical health about the same. However, in both situations, 53% report a worsening of emotional health in the last two months and 44% report physical health worsening. 

"Being in rooms with all the PP on for hours at a time is exhausting on another level that I not experienced before. Having to not only be the RN but also perform duties outside our normal scope, and be the virtual support for the family, has been really stretching." 

One of my favorite stories does not involve anyone in this room, or anyone in the Department of Medicine, but as an interaction between a nurse and an LIP. LIP came to see the patient and said "PTs sees patients in here?" The RN then responded "Yes." "Wow, that's surprising. I guess it's good for the patients, but it sucks for the physical therapists. "Why does it suck for the physical therapists?" "Well, the COVID thing." 

This is just like any other ICU. PP works. We all have to do it. The lived experience for the nurses and the nurse practitioners and all of us who've worked up there is that COVID patients get differentially treated in our hospital. They can't get the same things that all of our other patients get. And there's reasons for that. There's been reasons that we've wanted to limit that, but it's an ongoing challenge to get simple things like CT scans done. Or surgeries. 

And it's not to blame anyone, but it's to call it that we need to start thinking about how we can provide the same level of care to patients who have a disease that we're still learning about as the rest of the patients in the hospital. 

I want to boil down a little bit more into this emotional health. And there's a survey called the Professional Fulfillment Survey. It's a survey of a scale of one to 30. It's six questions. One to five. Three being sort of eh, five being great, one being awful. And if you look at professional fulfillment on people who have lower reported emotional health compared to higher, there is a little bit of difference. But it's not that extreme. 

And when you really start breaking it down though, what you do find is that people who have lower feelings of emotional health feel their work is less worthwhile than people who have high levels of emotional health. And so they feel that what they're doing is actually beneficial to society. But across the board, in providers, that includes nurses, and respiratory therapists, and others in the ICU, in acute care, the patients for the Special Passage unit, universally, they feel out of control in dealing with difficult problems. 

They feel very isolated up there. And I know you all know this, but I think it's something that, as leaders within our institution, we have to call out the importance of treating these patients right and giving power back to the front line providers. This experience is not unique. In a survey of European intensivist, with about a 20% response rate, which is about what I got to my survey, 46% support anxiety. 30% report depression. And burnout around 51%. Very similar in Wuhan, China. 

But it cannot be stated enough that it's not just us that is experiencing. The general population- 31% of people in the general population in July of this year reported signs of depression or anxiety that were new to them. 26% of them reported signs of PTSD. And 11% of our population, who had never thought about it before, were reporting concerns about suicide for themselves. 

COVID-19, and the winter that we have lived through for the past many months, has impacted us all. And those of us who provide this care, maybe slightly more. I know that this is something that we're all aware of, but this strain has revealed again that as providers, we are not good at seeking out help for ourself. 

In 2018, NPR had a mention about the fact that suicide is more common among physicians than it is among the general population. It's two-fold higher. But all health care workers are really experiencing this. And we have not found ways to support them. And in the words of one of my friends right now, was and don't tell me to do more effing yoga. 

We cannot do more with less. We have been asked to maintain and often increase productivity with limited understanding of how. Life has required more. Because many of us have families. Many of you have children at home on Zoom school right now. Many of you are dealing with loved ones who are struggling. Many of you are dealing with parents and grandparents and other things. Life challenges continued. 

I obviously went a little bit long here and I want to get through a couple of things. But I'm going to tell you one story then skip all the other stories about exposures. Occurred in April of 2020. I had been on the 9204 pager for a couple of days and I had refused- not refused, I had recommended against testing a patient because I didn't think they had COVID. Our community rate was pretty low. 

The next day, another person on the 9204 four pager said the same thing about the same patient. But 12 hours later, when asked again, we said yeah, you should test that patient. That patient was positive. Six house staff members were quarantined for 14 days because we didn't really know what we're doing. And we made a bad choice. 

COVID often made us choose between two bad things. We didn't have enough testing. We didn't have enough PPE. We did the best, but people got hurt because of it. 

I'm going to try to skip these because I see that we're getting low on time, but I'm going to tell you what we've learned about exposures. We've learned that universal masking and eye protection helps and we've expanded that. We also know that it's really hard to always do, then people fail. We know that small gatherings over a meal are risky. This is universally true, not just in health care. We know that we needed to close the Swiss cheese and we had a universal emission testing. And we're going to talk about some expansion around aerosolizing generating procedures. 

So what happened with asymptomatic testing? That started this week on Monday. Of the 471 asymptomatic patients tested, five have been positive, two of them have been here for days. So we have some more exposures there. But we will hopefully start capturing more of these people when they come in and not later on. We do know that there is still risk from visitors coming in and transmitting to patients. 

Employee testing started two weeks ago. And in the 700 employees that have tested that were asymptomatic, 11 have been positive. So we know that asymptomatic employees are out there. And that's why it's important for us to continue to wear a mask. That's why small gatherings over a meal are difficult. And heavens knows what we're going to do next week on Thursday when everyone wants to have a Thanksgiving meal to celebrate Thanksgiving but still has to work. 

Aerosolizing generating procedures are hard. We know that most of the data from this comes from 2002 to 2003 during SARS-COV1. It's different for different aerosolizing generating procedures. For example, nebulization, which is considered aerosolizing generating procedure, has an odds ratio in cohort studies of 0.9 for transmission of disease from the patient to provider. Whereas intubation has an odds ratio of six. 

So we've got a lot of work to do to try to figure out how we can make it safer during AGPs for our providers. And there's a lot of work going on around that right now. And I hope to be able to get that out to you all soon. But it's really this Swiss cheese model of prevention of respiratory disease. Physical distancing, better ventilation, mask, hand hygiene. All those things work. The same thing. Symptomatic testing, universal mask, employee testing. All really important. And we've got to continue to close those holes to try to make it safer for all of us. 

We know that the exposures have been really bad. 17,000 hours of contingency. That's my best guess based on what I was told 624 hours of sick time for the MICU alone in the last two weeks. And 40 years of experience lost because of burnout due to COVID. 40 years of bedside nurse experience in the MICU lost. People who have resigned. 

So what are our hopes? Well, this is the hope of one of our nurses. This is Mallory. In April, Mallory came into my office and sat down and says "Kyle, I have something to tell you." If a nurse practitioner walks into my office and says "Kyle, I have something to tell you," there's two options. They're resigning and moving somewhere else, or they're pregnant. 

Mallory told me she was pregnant at that point in time. No one else knows. I said "Do you want to stop doing COVID care?" And she said "Absolutely not. PPE works." This is Mallory this morning. She's, obviously, a little more obvious now. 

So what have we learned? Nationally and locally, SARS-COV2 continues to spread and there is no national plan to control it. We just have to state. That we need a local plan, we need local leadership, and we need national leadership. We have better treatment plans that we did in March, and we're still learning. And we've been part of the reason that we've learned. We're doing research here and academic medical centers need to continue to prioritize research and prioritize bringing the patients that we provide unique advantages to. ECMO. Mechanical ventilation. 

Transmission within our Special Pathogens unit has been very low. PPE works, but we know that exposures have occurred and people have gotten sick in the hospital, despite our best efforts. And we know that COVID is tiring. We're all tired. Everyone's tired. We don't really have much options to change that, and we're going to have to keep on going. But that's because COVID really is a marathon, which is why all the running pictures are in here. 

So what are my thoughts after 240 days? I think the sign on this bathroom really summarizes it for me. Whatever, wash your hands. And I just added in wear a mask. I think that we have to agree with Dr. Fauci that we have to be humble. We have to be flexible. Or maybe we should think about Jon Snow and just recognize that winter is coming. 

We also need to know that when the COVID vaccine comes, the Special Pathogens unit will need to be there. COVID is not going to go away soon and there will be other things that will require specialized care. We need to continue to encourage people to learn about how to take care of diseases that are scary. And we need to encourage our house staff and our students to be part of that mission. Because there will be another pandemic. There always is. 

And finally, I will just say two more things. We have to address the mental health challenges of our own community. That is, doctors, and nurses, and health care workers. But we also need to start becoming more unified and speak out when public health is being politicized and not being based on science. Because vaccines save lives. And with that, I'll take some questions. 

[APPLAUSE] 

SPEAKER 2: Thanks so much, Dr. Enfield. That was very powerful and we really appreciate you giving us all that information and sharing those really important stories. So we have some time for questions. For people who are in this room, if you don't mind asking questions with the microphone available so the Zoomiverse can hear, and then I will relay questions through the chat. 

SPEAKER 3: This is Eric. Thank you, that was terrific. I wanted to ask. You and a lot of others have done a lot to bring patients from other hospitals as much as you can. A comment you made about how academic centers are having better outcomes than smaller hospitals. Together with some comments critical care ground grand rounds yesterday. Are you aware of any academic centers that are really just bringing all the patients in? And potentially reducing some of the procedural volume to accommodate that? 

KYLE ENFIELD: No, there really isn't. And the challenge is that we've got a weird health care system in many ways. Mo taught me that when I was a PGY-1. But we don't regionalize our ICU. So if you look at European countries, including some that have not done well, their ICUs are showed on a tiering system, and they move patients through that system with a lot of transport, and a lot of expertise being applied locally. 

But we don't have that same approach in the United States. And because many hospitals are for profit, and not non for profit, there is also the concern about I'm stealing your patient to do that. And so unless we have some sort of nationalized mandate to change, which would fall under Congress and the Interstate Commerce Clause, in case anyone wants to know how that's legally possible, we can't do it. 

SPEAKER 3: Thanks Kyle. Great talk. 

SPEAKER 1: So a question from your critical care colleagues. So given that COVID rates, at least in Charlottesville, have been relatively low compared to some other parts of the country, when you think of your physician colleagues in New York or Houston, do you ever feel like you have a sense of survivor's guilt? 

KYLE ENFIELD: So yeah, totally. I know I have a sense of survivor's guilt. I also know that I can't- I felt very bad multiple times for not being able to go and help out. But it's one of the reasons that I want to remind all of us that our story is our story. So yes, our experience has not been what happened in New York. Has not been what happened in Chicago. But our story is still very real. And like many of my critical care colleagues, and many of the critical care nurses, I've been in the rooms holding the hands of people dying when their loved ones can't be there. And so while I do have some survivor's guilt, and I do have some concerns about that, I do also acknowledge that what I've experienced and what others have experienced has been very real. 

SPEAKER 4: Kyle, thanks so much for the great talk. And first of all, condolences on the loss of your dad. I see his picture out there and I know he was a great inspiration to you. I'm just curious. You know, I'm doing a lot of the community testing with a large group doing that, and we do see the LatinX population adversely affected compared to other races. Any thoughts on how we might address that or approach that? You talked about the systemic racism as well. So I'd love your thoughts on that. 

KYLE ENFIELD: Yeah. I'm going to try to figure out a way to share the talk that we had yesterday for critical care at grand rounds. I've got to find some way to put it behind a firewall because there were some things said that probably don't want to be put out in public. Jack Awashna, who is a good friend and a mentor, and a real deep thinker on this, really started thinking about that. And I think he poses more questions than answers. 

And I think what we have to do is some deep soul searching about what are the systems that we have in place that have led to that within the health care system? So much like we changed the way we think about quality improvement, it's no longer you did it wrong, you did wrong. It's what can I do better? What can we do better as a health system? And there's lots of things that incur that we don't even think about. 

Like how our transfer process works? Our transfer process is not forward reaching, it's reactive. And I think that's probably true in the public health issues that need to happen within our community. We haven't been forward reaching, we've been reactive. But I say that knowing that public health, if done correctly, is costly, timely, and the finances, from a budgetary standpoint, are not often there. 

We've all heard this, that health care in the United States is not a health care system but- is not a wellness system, it's really a disease system. And so I think that, to answer your question, I don't have a good answer. And while I have thought about it, I don't know that I am the best person to answer that. I do know that we need to think about how we can reach out rather than asking them to reach towards us. 

SPEAKER 2: I can tell this is a great talk because this question- the light is blowing up. But someone asked, since you did show that people at academic centers do better than those at community hospitals, do you know if there's any plan on a statewide, or at least at a health care system scope, how to distribute our resources for critical care? Should UVA be working to expand our ICU capabilities in order to be able to make transfers from rural under-resourced areas? 

KYLE ENFIELD: The only place that I know that comes close to this is in Massachusetts, and that's because they have an EICU system that requires you to be part of that EICU system to transfer. But there's no state plan on doing that for the reasons that I mentioned a few minutes ago. 

SPEAKER 2: And in your opinion, what else could UVA be doing to support their health care providers involved in COVID care? 

KYLE ENFIELD: Yeah, I think that that one is really challenging, and it's one that I spent a lot of time last night thinking about as I was going through this. I think first we have to acknowledge that it's painful and hard. I think that if we don't start with that acknowledgment, then we've missed some of the points here. 

I think we also need to help destigmatize the COVID units. I think that, intentionally, we built a system that isolated resources to a small space. We shoved it into a separate hospital. But we have to find ways to destigmatize. And one of the reasons I showed all the pictures of the nurses in the unit is to try to make people realize that these are real individuals working there. The worst comment that I've heard so far this month was getting on the elevator to go up to 4 South. And someone goes "Where are you going?" And I said "4 South." And they asked me "What's going on at 4 South." And I said "That's where the COVID ICU is." And the person goes "We have COVID patients here?" 

We need to do more as a community to acknowledge that. And then I think that we do need to start thinking about how we can give people time and space, in their workweek and outside, to actually take real breaks. And I think that being intentional about that is something we need to think about. But I don't have easy answers for that one either. 

SPEAKER 2: Great. And one last question. So first of all, many people said that this was an incredible talk. But as the numbers continue to increase, we seem to be possibly heading towards a lot of difficult choices regarding rationing of care. Are we as an institution prepared to make these tough choices, i.e. who gets a ventilator and who doesn't? 

KYLE ENFIELD: Yeah. So there's actually- so back in March, there was a group of people who actually got together, specifically segregated from the people who are actually doing the work. Which is an intentional thing, from an ethical standpoint, to decide how we ethically ration things. Tyson Bell, who I probably should have given more accolades to in some of the things I said here, worked with this to really reflect the impacts of systemic racism that can lead some of those decisions and to try to eliminate those. 

But there is basically, for lack of better words, there's an emergency response team to come in and help look through records if we're down to our last ventilator. What I will say, though, is that, in general, we are overstocked for ventilators. What we are not overstocked for is nurses. And for that matter, we're not overstocked for you all. So we'll run out of nurses and doctors before we're going to run out of ventilators. 

SPEAKER 2: Great. Thank you so much Dr. Enfield. And thanks for everyone tuning in and coming in person. 

KYLE ENFIELD: Thank you, everybody. 

[APPLAUSE]