Surge or No Surge, the Midwest Readies for COVID-19

Maureen Salamon

April 21, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Longtime Mohs surgeon Marta Van Beek, MD, has spent much of her career perfecting the precise layer-by-layer stripping technique central to her dermatology practice. It's a method that shares much in common with the COVID-19 duties she performs in her current role as a key administrator at University of Iowa Hospitals and Clinics in Iowa City.

Van Beek, who "somewhat reluctantly" became chief of staff in 2016, now finds herself integral to the hospital's painstaking efforts to respond to the crisis, evaluating procedures and policies layer by layer.

During twice-daily meetings of the incident command team, she has weighed in on strategic decisions about testing and personal protective equipment (PPE) allocation, staff and visitor screening, and extracorporeal membrane oxygenation (ECMO) and ventilator use.

Her post has also afforded her a unique vantage point for watching the pandemic play out in her rural Midwestern state and to prepare for Iowa's projected surge in early May.

As of April 20, Iowa had 3641 confirmed COVID-19 cases and 83 deaths. In contrast, the Northeast has been hammered with hundreds of thousands of cases and more than 15,000 deaths.

"Clearly, we're not anywhere near the crisis the coasts are facing," Van Beek said.

No stay at home order has been issued in Iowa, although large public gatherings have stopped, schools are closed, and restaurants and bars are providing takeout and delivery orders only.

But "no one knows the true prevalence of disease because of significant limitations on testing capacity, like in other areas of the country. We are bracing ourselves for the surge and prepping the environment and workforce for when it does happen," she explained.

We have the luxury of time to prepare.

"We have the luxury of time to prepare," Van Beek told Medscape Medical News. "Places on the coast did not have that luxury. It is one benefit we have. We can learn from them, and we've been watching closely to see what's working."

By early August, the Institute for Health Metrics and Evaluation predicts that Iowa will see approximately 600 deaths from COVID-19, which seems tame compared with the 60,000 deaths predicted in the country as a whole.

But the low estimate from a mathematical model designed in part to help hospitals prepare doesn't mean that Van Beek and her colleagues can rest easy.

University of Iowa Hospitals and Clinics sits in the center of the densest concentration of cases in the state, with more than 800 cases currently confirmed in its home and directly adjacent counties. In addition, the hospital's status as the state's only comprehensive academic medical center makes it a potential magnet for a disproportionate number of Iowa's hospitalized COVID-19 patients.

Van Beek and her colleagues are wary of models that suggest that peak inpatient numbers won't come close to filling their beds. "Everyone is looking at these models, but they're all based on imperfect data in unprecedented times," Van Beek explained. "I don't think anyone has enough information to make a really accurate prediction."

On April 20, the 811-bed hospital filled 32 beds with patients with COVID-19, including one child.

Bracing for a Worst-Case Scenario

"Our approach has really been to prepare for a worst-case scenario, in which our hospital would be full and we would have overflow units, and 80% of our patients would be COVID-positive," said Theresa Brennan, MD, chief medical officer at the University of Iowa Hospitals and Clinics. "But the likelihood of that is extremely low."

In early March, 2 months after the incident command team began daily meetings to discuss potential COVID-19 strategies, Van Beek had hoped to spend time triaging patients in the hospital's newly opened influenza-like illnesses clinic. By April 19, the telehealth-based program had screened more than 9100 patients remotely, pulling in more than 3000 for an in-person evaluation.

But those plans were derailed by the arrival of the hospital's first COVID-19 inpatient on March 11, which became the focus of intervention and a subsequent move to twice-daily incident command team meetings. Van Beek is used to having her plans change, however. Her election to the chief of staff position 4 years ago was itself a "huge diversion" from her beloved Mohs practice, which she continues on a limited basis.

When you walk the halls, it's a little Star Wars-y.

As in the rest of the country, the healthcare system in Iowa was quickly beset by worries about PPE levels. Even before the Iowa Department of Health implemented a PPE shortage order on April 10, the hospital was conserving masks and other gear. All employees are now wearing reusable plastic face shields with a visor-like brim, with added PPE if individual responsibilities require it, Brennan said.

"When you walk the halls, it's a little Star Wars-y," Brennan mused.

"When we heard about people elsewhere wearing a mask for a week and not having appropriate N95 masks, that really hit home for us," she told Medscape Medical News. "We're clearly not in a surge like other areas have been, but we've begun reprocessing our N95 masks [to sterilize them for reuse] because we don't know what the future will hold."

The Iowa team has also watched how hospitals in virus hotspots in other states have dealt with treatment challenges presented by COVID patients, so as to make the best use of what little medical evidence exists.

"Because COVID-19 is new, there's not much published evidence," Van Beek said. "We need to be constantly reminded to go back to what's biologically plausible," she added, and to use evidence "as the best mitigation against hysteria."

Surge or no surge, the hospital's approach seems to be working. One component of its influenza-like illnesses clinic program is a home treatment team for COVID-positive patients, which includes the delivery of a blood pressure cuff and pulse oximeter to each. Nurses call to counsel patients on how to take their vital signs and hospitalists check on high-risk patients each day by telephone or video chat.

Results of the initiative are impressive, Brennan said. Of the 200-plus patients managed in this manner, only nine have required eventual hospitalization. None have died.

"I think we've bent the curve in treating our patients," she said. "The model has proven effective in keeping patients out of the hospital and improving outcomes."

For her part, Van Beek is keeping close tabs on her staff's mental state as the crisis continues. As she does during Mohs surgery, she stands ready to pivot in response to ever-changing data and circumstances.

"Everyone has their own degree of angst," she said. "Worrying about faculty and staff, making sure people feel safe, that in itself weighs heavily on me. I do feel blessed to have a team."

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