Kelly Cawcutt, MD, MS, shares her thoughts on COVID's impact on health care, as well as why it's so important for clinicians to take breaks.
Segment Description: Kelly Cawcutt, MD, MS, professor of infectious diseases and critical care at the University of Nebraska Medical Center, and a Contagion® Editorial Advisory Board member, shares her thoughts on COVID's impact on health care, as well as why it's so important for clinicians to take breaks.
Interview transcript (modified slightly for readability):
Contagion®: Hi, I’m Allie Ward, editorial director of Contagion and joining me today we have a member of our Editorial Advisory Board, Dr. Kelly Cawcutt, who serves as professor of medicine in infectious diseases and critical care at the University of Nebraska Medical Center.
Dr. Cawcutt, thank you so much for joining me today. I want to start off and talk about how you are doing. What has your day-to-day been like the last couple months?
Kelly Cawcutt, MD, MS: Thank you so much for having me. How am I doing? I think I'm doing about as well as any of us can be. It's been really busy for everyone in medicine and, frankly, even outside of that, with schools closing and so many changes to our everyday functioning. But I've been busy spending my last several weeks doing a mix of infection control, in which we're really working on writing all of our policies. As we continue to move through this pandemic, with testing and procedures and how you reopen the hospital for more and more care. I’ve done a lot of education, which has been great trying to really help other hospitals, other groups understand what COVID-19 looks like and our infection control components, and then just some basic treatment-related discussions. Finally, I've been working in the COVID unit myself. So I've spent some time in our COVID ICU I as one of the intensivists, and I'm actually headed back there next week.
Contagion®: You just finished a week in the COVID ICU. What can you share about what you’ve observed regarding the clinical characteristics of COVID-19 at this stage?
Cawcutt: I think some of the pieces that are just really striking… As an intensivist, we would see patients who would have severe hypoxemia and acute respiratory distress syndrome (ARDS) in the past, and we've have people on ventilators in the intensive care unit, but our average length of stay, in general in a medical ICU, is really only a couple of days historically. With our COVID-19 patients—and this has been seen in many other institutions—we see substantial lung injury with severe hypoxemia and much longer durations of stay in the hospital, and many more patients requiring ventilatory support compared to what we normally would have used in the hospital settings, which we can all reflect on that as we think of all the prior shortages. We heard in Italy and early on in New York about running out of ventilators or ICU-level beds. That's the kind of impact that we're still seeing as we are stretched a little thin with patients coming into the hospital.
Contagion®: What sort of challenges are you encountering on the COVID wards?
Cawcutt: I think there're a lot of challenges still in making sure that we have great education to our frontline health care workers on the risks related to infection control, making sure everyone really understands how to use [personal protective equipment] appropriately. It's so critical on how we don and doff and we've seen some literature that shows some of the highest risk factors for getting COVID as a health care worker actually come down to whether or not you're doing good hand hygiene in that process. One of the classic things we've always worked on an infection control and always struggle to get full compliance to is one of the biggest things we see as an ongoing risk in health care in general right now.
I think there's a lot of drive to provide treatment for these patients with medications. And as you know, we have a lot of data that's evolving, but outside of remdesivir, which has just published preliminary data in the New England Journal showing a shorter duration of illness, we really haven't had great evidence-based medical treatments beyond supportive care as we would have in the past for any other patient with severe ARDS. Just that drive to have something to give these patients to treat to figure out how to do it safely and maintain that because we really don't have a clear end in sight for when we're not going to have these patients.
Something that has been echoing more so recently in the literature is really the visible disparity of groups that are affected and some of the hotspots, so seeing a lot of socioeconomic disparity in who is presenting to the hospital with severe illness and that's something that I think we are all struggling with how to assist and prevent disease spread in areas where there does appear to be higher risk. That's been a big deal in the Midwest with meatpacking plants.
Contagion®: What concerns come into play regarding the use and rationing of remdesivir for COVID-19?
Cawcutt: That's a really good question, and I think there're a few things that are really interesting about this. One is we're still under an emergency use authorization, and really FEMA has been given the capacity to distribute medication. It's a little unclear how that allocation is being done in full. We have received some for the state of Nebraska and the state really put a committee together to try and decide how to distribute that. There are variations based on how many patients you might have in a given hospital with COVID so there could be disparities where you see larger centers with more patients versus our acute critical access hospitals that may not have medication depending on how that is spread out. There're also the variations of institutions who have the clinical trials ongoing so the remdesivir studies are still ongoing with adaptive components right now happening. If you're at an institution that has the trials, there may be a different level of access to remdesivir based on if you are eligible and opt to enroll in a trial, versus having to get the medication under that EUA authorization. Unfortunately, there's a lot of potential for disparity regionally throughout the country and through different populations based on academic centers versus non-academic centers. I also think it's difficult because we know, even if we just look at the allocations that we have available here, there's not enough remdesivir to treat everyone who would qualify. Then it really may come down to each institution deciding how to ethically disperse medication and that's going to be a very difficult decision-making process that I suspect will not be standardized as you look from hospital to hospital.
Contagion®: Many states are in some phase of re-opening right now. What are the risks of reopening too soon?
Cawcutt: I think the risk is what we saw happening in Wuhan and what we've seen happen in South Korea and other areas where as you reopen—and the risk may be there regardless of when you reopen, for clarity, because we have not gotten rid of this virus—especially if reopening is matched with a kind of sense of security in the public that masking isn't as important, physical distancing from people isn't as important, hand hygiene isn't as important…We certainly run a risk of a second surge of infection. By no means did any of our communities see that everyone became infected with this. In these other communities like Wuhan and South Korea that led the way early, they have seen a resurgence of infection with second surges coming through as they reopen. I think that's something we have to be cautious of as we are reopening in states, that reopening does not come without risk, it likely does not come without more patients developing infection and coming into the hospital. We know that if we aren't cautious with it, we may, in fact, still have a peak that could surpass certain health care systems. That, to me, is the biggest risk—that we make this big initiative to flatten the curve and now that we're reopening, everyone assumes the curve’s flat, but they forget that it only stays flat if we maintain those policies as best we can while we reopen.
Contagion®: What do you see as the long-term effects of COVID-19 on the health care system?
Cawcutt: I think this will have in many ways revolutionized health care. It also, I think, really highlighted the fragility of health care as we know it. We've seen fragility with access to equipment, access to PPE. We've seen limitations of medications when they're being used at high levels more than historical precedent, or lack of capacity to manufacture. If one area is particularly struck with an infection, or other natural disaster, we may not have the supplies we need. I think looking at diversification of where medical supplies come from and how we research those will be one piece of this puzzle moving forward. But then honestly, it's moments like this. Not everywhere was really embracing telehealth and telemedicine and doing video conferencing. Medicine has, in many ways historically, fallen behind the business realms as far as adoption of certain technologies for so many reasons, including patient privacy and just capacity to execute appropriately. I think the use of technology that we've had almost forced upon us due to wanting to provide as much social distancing as possible is something that's going to be carried forward in medical centers in ways that was unprecedented pre-COVID. So I think that's going to be a huge shift.
I suspect as we carry this forward, the general infection control recognition and management and biopreparedness planning will really have a much more aggressive stance in health care centers across the world, and levels of education and awareness for all of our frontline health care workers regarding how critical it is to be prepared and to know how to do this every time, every shift, no matter where you are.
Contagion®: What is the single most important thing that you feel clinicians like yourself need to keep in mind during this time?
Cawcutt: I think that's a great question that I probably would have given varying answers to week-by-week, but coming into the weeks we've been at this, right now, I think health care workers really need to pause and remember that we need to take breaks, we need to rest. We cannot work unendingly whether it's at the patient bedside, whether it's writing policies, doing research, teaching. We can do this as a sprint the first few weeks and almost months that we have, but we are transitioning into a marathon phase and it's not sustainable without rest. It can't be sustainable without the risk of burnout or people becoming ill, or being so tired that they make mistakes in PPE donning and doffing and put themselves or others at risk. I think really recognizing the need to take breaks, to take time off. I know innumerable people around the country have revoked vacation. I did that much of the spring, and now it's really a scenario where we really have to do that. It's best for our brains, it's best for our mental and physical health. And, ultimately, if we maintain our health, that's what helps us translate that to the health of our patients, and the health of our colleagues, and the health of the country overall as we try to bring this system back up better than it was before.
Contagion®: Very well said. Dr. Cawcutt, is there anything else that you'd like to add?
Cawcutt: One thing would be to just again, thank everybody who's watching and working so hard and tirelessly to really fight COVID-19, to do the best that we can, to provide the highest standard of care in the safest place possible for as long as we possibly can. It is a tireless job, as I just mentioned, but it is something that I want to express my gratitude to everybody who's looking and listening, because I don't think we express the gratitude for the work being done enough. And sometimes that goes a long way, so thank you so much for the opportunity to do the interview today, but also thank you to everyone for the work you're doing.