Health Amplified | Year in Review

Podcast Transcript

Will Morris, MD:
Welcome to Health Amplified a Cleveland Clinic podcast. With us as always is Dr. Akhil Saklecha and this is Will Morris.

Will Morris, MD:
Today, we're going to do something a little bit different. We're going to do a year-in-review and a year looking forward. 2020 has certainly been one for the books and we've had unbelievable speakers, but the world is continuing to change. We thought this would be a great opportunity to reflect and also frame these conversations in the reality of what is going on certainly the pandemic.

Will Morris, MD:
Myself as a hospitalist and Dr. Saklecha as an ED, emergency department, physician experiences firsthand the impact of the pandemic, the stresses of our support staff in critical nursing staff, but also the economic and psychological toll on patients. With that, maybe I'd like to frame it with stories from the frontline and, Akhil, can you share a little bit with our listeners on what are you seeing and experiencing today versus say a year ago?

Dr. Akhil Saklecha:
I will. Sure. Thanks. You know, it's been a really, I would say, rough one year. Every month seems to be worse than the last and in terms of where we were pre-COVID to where we are post-COVID in the emergency department, there's actually been a significant change in the way we practice.

Dr. Akhil Saklecha:
I think that the biggest part is we never know whether a person has COVID or not. It means that we need to take precautions with everything that we do. That means not only just a mask, but in this case, we also wear goggles. We wear some type of hat or covering on our hair and oftentimes gloves. It's something we change out frequently between patients.

Dr. Akhil Saklecha:
We've always washed our hands. We've always taken great pride in doing that before and after. We're now literally we're at our workstations with sanitizers by our desk and sanitizing every five to 10 minutes, just thinking through all the different things that we touched. It's those little things that actually matter.

Dr. Akhil Saklecha:
But in terms of the patients that we're seeing in terms of the complexity, I've probably seen some of the most complex patients with COVID. COVID is more than just something that affects say respiratory alone. We've seen it cause multiorgan system failure where we are putting in not only a ventilator, endotracheal tubes and placing patients on ventilators, we're putting in arterial lines, we're putting in central lines, we're putting them on complex drips and management.

Dr. Akhil Saklecha:
The patients when they get sick are getting extremely sick, but you know, more importantly, it's also how we triage patients. The volume of patients that we're seeing means that we can't use traditional flow. We need to segregate patients in the waiting room. We can't have families come in with patients. Learning from those family members about complex histories becomes very difficult. How we register patients and collect demographic information to protect those registration personnel changes, how we route patients as soon as they come in and understand, are they there for potentially respiratory or COVID symptoms versus other symptoms, how we protect the caregivers in that collection process, all of that has been a significant workflow change. We constantly are revising based on new information and knowledge that we learn.

Dr. Akhil Saklecha:
More importantly, I think, Will, when I think about outside of the emergency department box, what I've seen in innovation that's occurred is actually at a high level. The pace of innovation has changed. It's more than just Eureka moments. I think now we're seeing people are constantly thinking about ways to improve the system.

Dr. Akhil Saklecha:
I'll give you one example. When we were first looking at how COVID aerosolizes in cardiac arrests, we started rethinking the way that we do CPR and actually, holding CPR in certain circumstances until we make sure the airway is secured. Even obtaining that endotracheal tube and securing the airway, inventors came up with what we call intubation boxes, where it's a large plastic box or bag where you have the hands coming in through arm holes and you're intubating the patient through a protective covering so that you don't have the aerosolization. Those are the things that come up where that pace of innovation, the creativity from inventors to come up with ideas and work around and solutions.

Dr. Akhil Saklecha:
We've seen it with 3D printed ear guards to protect mask, and we've seen it with 3D printed ventilator valves and mass. At Cleveland Clinic, we had our own High-Line solution with how IV lines are managed with tubing. That collaboration that pays doing things anywhere and any time has been substantial and had been a big thing that we've seen this year.

Will Morris, MD:
I could not agree more. If there's a silver lining out of this is how ingenuity, creativity, passion can really break down barriers and you're right, it's not these Eureka moments. It's how do we think differently when faced with unprecedented unfathomable challenges.

Will Morris, MD:
I never thought I would be more appreciative of the simple little adhesions that go under the eyes when you're wearing a mask so it doesn't fog up your face shield. Little things like that, I will tell you save the day because otherwise you can't see.

Will Morris, MD:
I have to say just as I reflect back from the year and think about some of our speakers, you talk about PPE and originally it was, "Hey, we just need PPE". Now it's, "Actually, we need it differently". We need to rethink about it and how do we actually rather than having solutions to fit a problem, how do we define the problem and then build out net new solutions?

Will Morris, MD:
I think this is to me the silver lining is how this can make innovation, those frontline caregivers feel more empowered, more supported to have a voice and be part of the solution.

Will Morris, MD:
Curious, the psychological toll. We talked about obviously managing the physiologic impact, the stresses of the economics of COVID the need for beds and managing how are people coping? You've got a higher severity of illness patient, you've got family that usually helps support the patient in their time of need, but now the burden is on you or your nursing staff. How are you managing? How are your teams managing and do you see a space of innovation around that?

Dr. Akhil Saklecha:
It's been tough. I think I've seen situations where, because of the limitation of really protecting everyone and having the patient in the room without family when they're really sick, it's created problems I think in how coping is done for not only the patient, but also the caregivers. It's tough when there's someone who's really sick or you have someone who's very frail or someone who normally has a lot of family around them and suddenly it is without that structure of support. It creates a dynamic where it is tough to recover and that handholding is important.

Dr. Akhil Saklecha:
If we look at it from the patient's side, that recovery is not always just about what we look at vital signs or the actual organic health, it's also about mental health. I think that that loss has a longer term implication. I don't think we've seen really the end result of that. I think we're still early in that process.

Dr. Akhil Saklecha:
I think on the caregiver side, it can be rough when you have sick patients and you have multiple sick patients and you don't have enough time to recover from patient to patient.

Dr. Akhil Saklecha:
In the ER, I think we're used to seeing ill patients, but seeing them sequentially hour after hour and to a point when there's overload as we are in now, it is difficult.

Dr. Akhil Saklecha:
What I've seen, I think on the innovation side is we start seeing a lot of startup companies focused around mental illness. It goes from the gamut of not only handling things when there is a crisis and having virtual group therapy, virtual psychology therapy that's one-on-one, but also things that are more around relaxation and meditation techniques and things that people can do maybe on a daily basis, or a few times a day where you can actually calm down and be proactive and protective of mental challenges that are yet to come.

Dr. Akhil Saklecha:
I think that we've seen startups react in that sense. Mental health has been a big white space area, an opportunity and I think we've seen a lot of advances in this last year around that area.

Will Morris, MD:
Yeah. I agree even sometimes the most simplest act of just being quiet. I know at least on the inpatient side, whenever we have a patient who has passed, the team gathers and it's for a minute and just is quiet and reflects. I think that is exactly right in this fast, fast, fast, unprecedented pace of what's going on with COVID. Shame on us if we don't recharge the batteries and think, because it's A, that's healthy. B, that's truly the inventor mindset is one that is fertile and right for creative thinking.

Dr. Akhil Saklecha:
Will, let me ask you. We've done a few of these talks this year with topics that's something to do with supply chain and Brian Donley, with London and Kelly Hancock and Nancy Albert regarding the Year of the Nurse. As you look back on these different topics, what are some of the things that were memorable for you that really stuck out and you felt really hit a note with you?

Will Morris, MD:
I will say the universal theme across is the concept of the team solutioning. None of these were necessarily an out of one. Certainly there was a need, but there was a group that validated this need. It became an echo chamber to help co-create, evangelize in solution. The spirit of the collective creative process is very, very profound and I think reflects the nature of COVID because COVID is a team sport to manage. Maybe I'm reaching for something that's not there that innovation and COVID has that same kind of necessity of teams coming together to manage.

Will Morris, MD:
As I reflect some of our speakers, whether Brian Donley talking about building a hospital in the middle of London or Barry talking about one day seeing patients and the next day having to convert 70% to virtual, that requires an unbelievable coordination of people in esprit de corps. That to me gives me the greatest degree of hope and solace.

Will Morris, MD:
What about you?

Dr. Akhil Saklecha:
Every speaker had a different perspective on how it affected them and what they were trying to achieve. I think if I was think through every one of them, I mean, they were really unique and we gained a lot of valuable insight.

Dr. Akhil Saklecha:
One of the ones that struck out to me was around supply chain and how to me very early on in this crisis, the first things that you start thinking about are where are the rate limiting steps that will impact us. It always came down to, are we going to have the right type of equipment? Are we going to have the right type of medication available? Will we have enough support and backup on all of those things?

Dr. Akhil Saklecha:
It came down to managing supply chain, understanding in situations where we only had single source making sure we had more multiple sources. I think about the mask effort and our ability to say, "Do we need to actually get into the business of sourcing masks ourselves by manufacturing it, or going further upstream and making sure we understand that entire process?" It even revolved around hand sanitizers and working with breweries to get some of that made. I think the creativity around that, because it was such a high value area was substantial. I learned so much in that conversation.

Dr. Akhil Saklecha:
I don't know, Will, maybe you can go into a little bit of the mask effort at a high level and even about what we're doing going forward around some of the brand new activities there?

Will Morris, MD:
Yeah. I know. Out of the whole pandemic, that concept of this is classic crisis management, where you have to have capacity and goods, whether it be syringes or masks, PPE in this case, these unplanned but unprecedented consumption models, and how do you create that stockpile, how do you create that distribution change. It's opened up a real interesting dialogue with supply chain, our local state and federal officials, local manufacturing to come together and solve this.

Will Morris, MD:
We're not asking them to now get in the business of creating masks from now on and until eternity. Once we reach a steady state, I think the usual suspects and the usual process rules. But we need to redefine what happens when a crisis hits and how do we rather than disposable use once masks or equipment, think about the concept of reusability so I can store it, but at least can you use it for the acute moment? We're redesigning and rethinking how we inventory, stock, manage and then distribute these products. There's one aspect that we're working really, really closely think about that.

Will Morris, MD:
The second piece is what is our role for the community? As COVID has demonstrated, this is not just about the patient that comes into the emergency room, or the patient that's admitted in my care, it's around supporting the community and keeping them safe.

Will Morris, MD:
We have a role, even as a health provider, we have a wellness in the life provider aspect, and we want to leverage our brand to support that. We've been really, really fortunate in aligning ourself with manufacturers, Standard Textile, which is a national ... You wouldn't know them, but they're the ones behind many of the sheets and fabrics if you remember staying at a hotel ever. How do we leverage them, but also create a community-based face covering that is wearable, but sends a message to the community and into people that it's so important? Everyone has a duty and everyone can do a part to manage this pandemic. Just like you're managing that acute patient when they're coming in and gasping for air so can the population, and we feel our job is to empower that. We have a relationship with Standard Textile.

Will Morris, MD:
We have a relationship with Off-White, who is a company based out of the work of Virgil Abloh. The idea is how do we tap into the youth activism movement? How do we create momentum in conversations that everyone has a job in this aspect?

Will Morris, MD:
Then lastly, I think, if I had a wish for 2021, it's the year of the vaccine, not the year of the pandemic. We're done with the pandemic. We want the year of vaccine and really address the social aspects, the health disparities, but also creating this dialogue that we need the community.

Will Morris, MD:
I'm hopeful that as we look back, as I look back, this is the year of collaboration and teamwork and ingenuity. As I look forward, I hope we learn and leverage that aspect and apply it to the next pandemic, which may not be a viral pandemic. It might be something like health disparities.

Dr. Akhil Saklecha:
Will, I think you bring up an interesting area as we shift and think about what's next, right? If we think about 2021 and beyond, we think about going from vaccines, we think about focus on antiviral medications, we think about more point of care testing, over the counter testing. We think about surveillance and monitoring, all those things. There's all this innovation that needs to carry over, but be advanced, as we focus on not only COVID and the remnants of COVID, but preparations for emerging pathogens.

Dr. Akhil Saklecha:
I know you mentioned a different type of pandemic, but if I think about even the innovation that will continually go forward so that we're not in a situation like this and that we not only become more proactive, but we become preventative, will some of the behaviors actually continue? Will we actually see more and more people being careful about what they touch, making sure they're washing their hands? Maybe we're going to see something where people are going to be continually to wear masks for a while.

Dr. Akhil Saklecha:
To me, even if I think about the behavior change issues, I also think about the model changes we've had. We've seen a big shift to telehealth this year. Will that continue? Right?

Dr. Akhil Saklecha:
I think what we were able to do this year as we jump-started telehealth and when we went totally to one extreme, we may see it come down to allure and range, but we need to make sure that regulatory hurdles stay the way they are and be the managed, reimbursement stays the way they are and be managed.

Dr. Akhil Saklecha:
I'd be curious on your take to see, what do you think about some of those innovations that have carried over this year and got jump-started going forward? Do you see that continuing to the degree we have now, or plateauing out or decreasing? How do you look at that?

Will Morris, MD:
Yeah, no, that's a great, great question. I think my perspective is we are at one end of the extreme and, and there will be a settling and a normalization. All of these experiences, whether it be telehealth or virtual visit or using a chat bot are tools in the toolbox. How do we ultimately continue to drive the best care for a lower cost, but also consider what the patient experience is?

Will Morris, MD:
I'm hard pressed to think of going forward for my six-year-old, who has an earache, going into the pediatrician office and potentially contaminating or be being contaminated and contributing to the gumming up the system, when I can participate in a virtual visit. They're not feeling well. They don't want to sit in the car. I don't want to sit in the car with them and yet they can get the same quality of care, same quality of diagnosis, and actually get it more rendered quicker. It's cheaper, it's better, it's quicker. The pediatricians love it. The child loves it. The parents love it. I'm scratching my head going, "We're going to go back?"

Will Morris, MD:
Now, certainly not all things can be done virtual and so there's like anything, a tool is only as good as the problem that you're trying to solve. It's the right tool to the right problem. I am very, very bullish for the concept of telehealth and that means both a visit, a virtual visit with video or even asynchronous, where you're actually communicating. We see that a lot with it, absolute astronomical number of patients just emailing us. I think that's very, very powerful and so I don't see that going away. I think that there are new payment opportunities, policies are being helped to make it easier for providers and for patients to access the care they need when they need it, regardless of where they are.

Will Morris, MD:
To me, that is an absolute win. We're not going to go back. We need to continue going, and we need actually more innovative companies to help us on that journey.

Dr. Akhil Saklecha:
I would have to agree. As we wrap up this episode, Will, tell us what we have lined up going forward over the next few sessions.

Will Morris, MD:
We're really excited about our upcoming podcast. We have Dr. Dweik who is the Chair of Respiratory Institute, wears two hats. One is he's obviously managing an unbelievable ICU burden across our enterprise for this disease, but he's also an innovator. He's thinking about how to leverage breath tests, how to manage the condition, the impact of the lungs going forward. I think it will be a tremendous dialogue on the innovations, both managing a pandemic, but the sequela, the output of that.

Will Morris, MD:
Second, we have a conversation with Dr. Rakesh Suri who's the CEO of Cleveland Clinic Abu Dhabi, and like our conversation with Dr. Donley we'll continue discussing the role of regional international innovation. Certainly the United Arab Emirates has a rich history in galvanizing and bringing together unbelievable service lines and funding them healthcare being one. We are blessed to actually have one of the anchor institutions.

Will Morris, MD:
Then lastly, we have Bill Peacock, who is our chief operating officer of Cleveland Clinic, oversees the IT infrastructure as well as supply chain and our international business. I think from his perspective, how do you orchestrate this massive game of chess when the game is changing the rules and what he sees are important investments in addressing not only this pandemic, but going forward, how to make ourselves more resilient.

Dr. Akhil Saklecha:
Will, that sounds incredibly exciting. Looking forward to all those conversations.

Will Morris, MD:
Then you just get to work with me too, Akhil. I mean, that's the biggest blessing.

Dr. Akhil Saklecha:
I appreciate it every day. Believe me.

Will Morris, MD:
All right. Well, it is on that we wish you all the health and wellness for a healthy end to 2020, but more importantly, we are blessed to have you back for 2021, an exciting continued chapter with Health Amplified, a Cleveland Clinic podcast.