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How are Hospitals Preparing for COVID-19?

March 13, 2020

to Public Health On Call, a new podcast from the Johns
Hopkins Bloomberg School of Public Health. Our focus is the
novel coronavirus. I’m Josh Sharfstein, a faculty
member at Johns Hopkins and also a former Secretary of
Maryland’s Health Department. Our goal with this podcast is
to bring evidence and experts to help you understand
today’s news about the novel coronavirus and what
it means for tomorrow. If you have questions,
you can email them to [email protected] That’s
[email protected] for future podcast episodes. Today, I’m talking to Dr. Lisa
Maragakis, the senior director of infection prevention for the
Johns Hopkins health system, about how hospitals
are preparing to care for patients with
COVID-19, the illness caused by the novel coronavirus. Let’s listen. Dr. Maragakis, thank you
so much for joining me. LISA MARAGAKIS: Thank
you for inviting me. It’s really an honor. JOSHUA SHARFSTEIN: So tell me
a little bit about your job here at Johns Hopkins Medicine. LISA MARAGAKIS: Sure. So I am an infectious disease
physician and a faculty member in the School of Medicine. My primary role, however,
is as senior director of infection prevention
for the Johns Hopkins Hospital and the Johns
Hopkins Health System. JOSHUA SHARFSTEIN:
So that’s a big job. And it’s even bigger with
the novel coronavirus. So tell me a little bit
about what is on your mind as you think about preparing
Johns Hopkins for a potentially new type of infection. LISA MARAGAKIS: Sure. Well, my colleagues and
I in infection prevention are always focused on
preventing infections amongst our patients,
our staff, our visitors. And that threat can
take a variety of forms. It can be device
related infections, procedure related infection. So we work a lot on
policies and interventions to make sure that
everyone’s doing all we can to prevent infections. When something like the novel
coronavirus comes along, it presents an
enormous challenge just for preparedness
in the hospital setting and in the health care
delivery system at large. Really thinking about
every aspect of how a respiratory virus might
be transmitted and taking steps to prevent that. JOSHUA SHARFSTEIN: So
let’s talk about what that looks like in practice. You must be worried that someone
with this might come into the– maybe worried is the wrong word. You must be thinking
that someone like this might just come into
the emergency department with a cough. From an infection
control perspective, what does that
bring up right away? LISA MARAGAKIS: You’re
absolutely right. The most important
principle when we are in the period
preparing for a pandemic is to think about
how we’re going to be able to identify
patients who are at risk. We have several strategies. One strategy is
travel screening. So at the beginning, when there
were certain countries that had ongoing transmission
of the novel coronavirus, we implemented travel screening
so that we would be aware. And asked every patient who
presents to our emergency department, or a clinic, or
really any portal of entry to our system about
international travel in the preceding two weeks. And then if they had that
international travel, then we proceeded to ask
them about their symptoms, and thereby try to identify
who was at the highest risk and had some
epidemiologic link, and so symptoms that
would be concerning for coronavirus disease. As the virus has spread
around the world, it’s been more
difficult because we would say the epidemiologic
link has been broken. It’s a little bit harder to
tell who might be at risk when it’s more widespread. JOSHUA SHARFSTEIN: So how
does that change practice? Somebody comes into a clinic,
what are you advising? LISA MARAGAKIS: So it
changes the challenge. It makes it an enormous
challenge, actually. We’re still in the middle
of respiratory virus season. So we have patients
coming in regularly– JOSHUA SHARFSTEIN: With
flu, other viruses. LISA MARAGAKIS: Absolutely. Respiratory symptoms
are very common amongst the general
public and our patients. And so then looking
for the novel coronavirus becomes a little
bit like a needle in a haystack. We turn more then to strategies
like standard precautions. Knowing that, we have to
assume that almost anyone could have the virus, whether
it’s influenza or this novel coronavirus. And make sure that we take
all kinds of precautions, including excellent
hand hygiene, washing our hands frequently, using
alcohol based hand sanitizers. Really advising people to
be very mindful about being in close proximity with someone
who is coughing and sneezing. Using something like respiratory
etiquette, which really is a term that we
use to encompass all kinds of strategies–
covering coughs and sneezes, making sure that we wash our
hands, and things like that. But patient care
is really we need to turn to personal
protective equipment. JOSHUA SHARFSTEIN: Got it. So during this period– when testing is not
widely available yet. LISA MARAGAKIS: That’s
been a huge challenge. JOSHUA SHARFSTEIN: Yeah. Tell me a little bit about that. LISA MARAGAKIS: Right. So all of the testing so
far has been concentrated in the hands of the Centers for
Disease Control and Prevention. So there’s been a delay and a
need to call the state health department. Have a conversation. Collect samples. Send the samples to the
state and then to the CDC. And so it’s taking a matter
of days to get results. More recently, just really
within the last several weeks, test kits were sent out to
state health departments. Unfortunately, some
of those didn’t work and had to be taken back
to the drawing board. So it has been a frustrating
roadblock, really, to our ability to be able
to tell who has this virus. JOSHUA SHARFSTEIN:
As testing stands up, and probably testing
will eventually be able to happen right
here in the hospital. LISA MARAGAKIS: Right. That’s the goal. JOSHUA SHARFSTEIN:
Then you’ll have to come up with new
protocols for in this process of universal precautions
when you’re actually looking for the novel coronavirus. LISA MARAGAKIS: Exactly. So if tests were more
widely available, and if results could be
obtained more quickly, then we would be
able to tell who has the virus, who
doesn’t have the virus, and take actions based on that. JOSHUA SHARFSTEIN: So
one of the important jobs of infection control is
protecting the people who work in the hospital. LISA MARAGAKIS: Right. JOSHUA SHARFSTEIN:
And there’s so many great nurses and doctors. But there are also great
respiratory therapists, great janitorial staff,
great custodial staff. There’s so many
people who are devoted to the mission of
taking care of others at Johns Hopkins
and other places. LISA MARAGAKIS: Absolutely. It’s a team approach. JOSHUA SHARFSTEIN: Yeah. And so it is an enormous
responsibility thinking about this, to protect them. Especially given the fact
that in other countries, there have been quite
a number of health care workers and
people in hospital settings who have been infected. So how do you talk
to the team here? How do you think about
that responsibility? LISA MARAGAKIS: Right. Well, you’re absolutely right
that it is an enormous task to really think about the whole
operation and everyone who’s involved. Everyone who works here, no
matter what our job might be, comes in contact with our
patients, and visitors, and our colleagues, and
staff on a regular basis. So a lot of it is the challenge
of sharing information, making sure that
everyone has access to the latest information
about the current situation. And our guidance
and public health guidance about how to protect
yourself, your family, and your colleagues. And then specific guidance
in the health care setting about how to protect patients. And to take precautions
so that we ourselves don’t pick up the virus and
then transmit it to others. JOSHUA SHARFSTEIN: So one of
the challenges from California is they had a
patient and they put to hold on to the hospital
staff on sort of self quarantine basically. People who weren’t
sick at all had to stay out of the hospital. LISA MARAGAKIS: Right. JOSHUA SHARFSTEIN: For
me, it raises the question of how many times can
you do that and still have anything left
in the hospital to take care of patients? LISA MARAGAKIS: You’re
absolutely right. JOSHUA SHARFSTEIN: How do you,
as an expert in this field, you’re balancing the importance
of having staff in the hospital with the fact that you don’t
want the disease to spread. How do you balance those things? How do you think this
is going to play out? Or what are your thoughts? LISA MARAGAKIS: Sure. Well, I would say we
can’t let the perfect be the enemy of the good. We do have a principle
in general of erring on the side of caution. And so if we had one exposure
that involves some health care employees, and we wanted
to put them on quarantine, have been furloughed
from their job during a period,
that is certainly an approach that we would use. However, in this
kind of a situation, we have to think to scale. And as you’re alluding to,
we really cannot afford to furlough our health care
workers in large numbers, or we won’t have anyone to
take care of the patients. So we are thinking
through strategies about how we will
really determine the level of exposure. If people follow the
protocols and use personal protective
equipment, the good news is that infection
prevention works. And we know that we can
care for patients safely, minimize those exposures. And then really use furlough
in a very conservative manner so that we’re not
crippling ourselves by furloughing large
numbers of our workforce. JOSHUA SHARFSTEIN: You
make an important point. For hospitals like
Johns Hopkins, you take care of pretty
serious infectious diseases on a regular basis. LISA MARAGAKIS: Correct. JOSHUA SHARFSTEIN:
Tuberculosis, not to mention– LISA MARAGAKIS: Brucella. JOSHUA SHARFSTEIN: Brucella,
influenza, and if I recall, you were ready for Ebola. I don’t know if you
got an Ebola patient, but you had the capacity
for an Ebola patient. LISA MARAGAKIS: We
have an infrastructure and a biocontainment unit and a
trained group of staff members who are standing
ready at any moment still today to take
care of a patient with viral hemorrhagic fever. JOSHUA SHARFSTEIN:
So this isn’t exactly like starting from
a standing stop. LISA MARAGAKIS: Correct. JOSHUA SHARFSTEIN: You are
in the business of handling infectious diseases. And this is the new one, which
has certain characteristics, but you’re sort of turning
the enterprise to address it. LISA MARAGAKIS: Absolutely. It’s such an important point. And I think that
the resources that were made available during
the Ebola crisis in 2014 really enabled us to put
an infrastructure in place for that readiness. And as you say, it’s
allowed us to pivot from that type of preparedness
to this type of preparedness. And I would say that throughout
the whole time that we’ve prepared, we really knew that
pandemic respiratory viral illness was the true
threat that we could count on coming around again. It has a way of doing that. JOSHUA SHARFSTEIN: So
how does this situation change your day to day work? I noticed that one of
the conference rooms has been converted into a little
bit of a command center, where people are busy doing
all sorts of things. From your perspective,
what changes for you as you’re thinking about this? LISA MARAGAKIS: It has
been an enormous change. I would say that we
began this work as soon as we heard about this virus. And began in earnest our
preparations in January. So we have spent several
months now, at least 2 and 1/2 months,
working towards a true comprehensive plan
for how to operationalize our preparedness efforts. However there have
been stages of that. So at the beginning, we
divided and conquered. We had half of our team
continuing normal operations, and approximately
half of our team working really around the clock
on this kind of preparedness. I want to say that we are
partnering with our emergency management colleagues
very closely in this, and learning so much from them
about the value of incident command, and how that
can leverage colleagues and infrastructure across the
organization to really help with a readiness effort. But as the pandemic has evolved
and spread has continued, the level of activity has
escalated exponentially. So we are really
having to set aside some of our other
projects and normal work, and really all hands on
deck for this effort. JOSHUA SHARFSTEIN: I know
as a former state official the work that happens
at Johns Hopkins, other places becomes
extremely important to the overall preparedness
of a city or a state. And in addition to the
work you’re doing here, people must be calling
you and saying, what should we do
at the state level? What should we do
at the city level? I know I was calling you
a few years ago on that. So you’ve got to
handle your job here. You’ve got to advise other
people about their job. You have to be in contact
with different things that are going on and be
ready to speak up to make sure that there
are not any policies that are undermining the work
you’re trying to do. LISA MARAGAKIS: You’re
absolutely right. At Johns Hopkins, it is a very
large and complex organization. And we are critical partners
with public health authorities at the city and the state
level, and throughout the region and nationally as well. So there’s a lot of
coordination and conversations. And for our enterprise here,
you know it’s a two way street. So we are looking to the
public health authorities also to help lead
that regional approach and how that might
impact our preparedness. JOSHUA SHARFSTEIN: So
last question for you. There are a lot
of people who are anxious about this new disease. And we’ve gotten all
sorts of questions. We set up a way for people
to send in questions. We got over 700 questions. LISA MARAGAKIS: Wow. JOSHUA SHARFSTEIN: A lot
of them have to do with, should I travel here? Should I travel there? What do you think? A lot of them have to do with
their own personal health situation. I have this condition. Does it make sense for me
to keep taking my medicines? Other things like that. I think that the unknown is
such a big source of anxiety. And I just wonder from your– what message you would
send for what people can do realistically now? How they should
think about this? Knowing that there are a lot of
places like Johns Hopkins that are really prepared, that
they see this as their job. How does that help in
some ways to address some of that kind of
unformed anxiety out there? LISA MARAGAKIS: Well,
I think as you’ve described very well,
that fear and panic can be as paralyzing as disease. And it sometimes
becomes a barrier to taking concrete
actions for preparedness. So I guess my advice
would be to remain calm. And take comfort in the fact
that organizations and health care professionals are
making these plans, public health authorities
are making these plans and implementing them
to keep our communities and our patients safe. And then I think
it’s very empowering to take concrete
steps of your own for your own preparedness
at home, for your family. It’s not unlike preparing for
a weather event or something. The same kinds of
considerations come into play. And then finally I
think I would say it is frightening to have a pandemic. But I think that we can
look at the overall picture and know that the
majority of people, even if they get
this disease, are going to have relatively
mild or self limited illness. And so that should be
somewhat reassuring. And I would have a
request of people that if and when
that happens, it’s very important to reach out
for medical input and guidance, but don’t necessarily rush
in to clinics and emergency departments. Because just realize that
you’re part of a larger system, and we want to have everyone
get the care that they need. We are putting strategies
in place, however, to help support people
to recover at home. And using telemedicine,
and other strategies, home care colleagues to provide
services and advice, and allow those worried well and
mildly ill to get through this without necessarily exposing
others in the health care setting and also saving
the resources for those who do become more ill and need it. JOSHUA SHARFSTEIN: So in other
words, know that you’re here. But also know that
everybody can do things to protect themselves too. LISA MARAGAKIS: Absolutely. We can all play a role. We all need to play a role. JOSHUA SHARFSTEIN: Great. Well, I certainly feel
much better having had this conversation. Thank you so much for taking
the time to talk to me. LISA MARAGAKIS: Thank you
so much for having me. JOSHUA SHARFSTEIN: Thank you
for listening to Public Health On Call, a new podcast from the
Johns Hopkins Bloomberg School of Public Health. Please send questions to be
covered in future podcasts to [email protected] That’s
[email protected] This podcast is produced by
Josh Sharfstein, Lindsey Smith Rogers, and Lymari Morales. Audio production by Niall
Owen McCusker with support from Chip Hickey. Distribution by Nick Moran. Thank you for listening.

1 Comment

  • Reply François March 11, 2020 at 6:07 pm

    ⚠️ Thank you for this video. Are there special written protocols for patients with Ehlers-Danlos and other collagenosis, regarding the COVID-19, please ? As a French patient I can see that in Europe in general, physicians do not take this pathology seriously and, worse, know little about it. Thank you very much in advance for your help.

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