Tackling the Pandemic from a Military Perspective

Podcast Transcript

Will Morris, MD:

Welcome. This is Will Morris, executive medical director of Cleveland Clinic Innovations for another Health Amplified, a Cleveland Clinic Innovation podcast. And with me as always is Dr. Akhil Saklecha, managing partner of Cleveland Clinic Ventures. Today we have a tremendous guest, a partner of us in Innovations and Ventures, William Peacock. Bill Peacock is the chief of operations of Cleveland Clinic. 24 years as a captain in the Navy performing the role of a civil engineer. He is at the intersection of how operations meets innovation and care delivery. Overseeing information technology, supply chain, global operations. Bill is literally at the crossroads of not only how we perform our duties and how we can manage patient care at these unprecedented time, but how we build fortitude and resiliency for the years ahead. Bill, thank you so much for joining us. It's an absolute pleasure.

William Peacock:

Dr. Morris, it's a pleasure to be here. Thanks for inviting me today. And Dr. Saklecha, thank you for inviting me as well. Thank you.

Will Morris, MD:

Well, I'll start off obviously, this is the year that truly pressure tests an organization's ability to withstand unprecedented patient volumes, unprecedented caregiver pressures, and supply chain issues that I don't think anyone has ever anticipated. Tell us a little bit about how you lead through this change, and perhaps even tapping into your years in military service and how that actually allowed you to think innovatively and in guiding us through these in dire times.

William Peacock:

Well, it's hard to pick where to start, but I guess if I take myself back to February and the January time watching the disease migrate its way across the globe, just at home, on my television, watching CNN and others, and then logging into the Johns Hopkins website and the other websites that were showing that color radix floating across to Asia and the China market, then making its way, and then these little episodic events happening both in the Portland or Oregon, Washington State area, and then on the East coast as well. It became readily apparent that we were in for something. And I don't think we quite knew what at the time, but one of my colleagues that sits right next to me in the office suite up here as the chief of medical operations, and I've always worked very closely with him, with our disaster preparedness operations, our command centre.

William Peacock:

We thought early on that it was important to up the command centre and start tracking how this virus pattern was going to migrate. With the international hat that I wear I was fortunate to have a purview into what was happening in the middle East with the virus. So we were able to see an earlier episode of this virus in Abu Dhabi, but also through international... the clinic has been an international organization since inception back in '21. Our connections with physicians globally was incredibly important. We were able to hear firsthand how ICU docs were completely overwhelmed in Italy. We were having conversations in the command centre with Italian intensivists that were trying to manage an incredible overflow of ventilated patients.

William Peacock:

So we were able to use that information, our business analytics team, to make projections and estimations of what kind of patient volume we would see as early as the February and March timeframe. And the early numbers they were quite alarming. We thought at one point that our Northeast Ohio market might be besieged with over 8,000 patients. We don't have that many beds in a market. We only have close to 4,000 and we're still trying to provide other cares. So questions, do we need a surge capability? Do we need some ways to expand the number of available beds? On the equipment side, we were very concerned that we might not have enough ventilators. We were very concerned we might not have enough PPE.

William Peacock:

You asked me about my military experience, when this event happened it reminded me very, very much of how we in the military prepare for chemical or biological warfare, and how we use to drill, drill, drill, and how to dawn our protective gear, dough our protective gear, check each other, and present to each other that we were completely sealed and safe. You as many of your listeners probably know, and your viewers, we didn't know if this was a surface virus, the legacy of this virus and how long it would be in the atmosphere. There were a lot of unknown unknowns about this virus when we were in the spring of 2020. So we had to plan for the worst. We saw the supply chain for a lot of the protective gear heavily compromised over the years in an effort to control costs.

William Peacock:

Many of our major distributors for a lot of our PPE had leveraged low cost industrial markets in both Mexico and in China to obtain a lot of the face masks and the gowns and the shields that would be needed to amplify the protection of our caregivers. Nasopharyngeal swabs and the flocking material that it goes on the end of the tips, we found a lot of that actually comes out of Italy. So it forced us as an organization to look beyond our normal limits of our supply channels and go much further back. The ventilator issue, I think any of your listeners would be familiar with the concerns that we had nationally on ventilator supply. Of course we saw the country resort to things like the conversion of industrial plants into ventilator production facilities for a renewal of a national stockpile.

William Peacock:

We were concerned we didn't have time for that production run to take place. So we partnered with a local aerospace manufacturer who had a really strong 3D printing capability to see if we can make splitter valves. And we must've gone through dozens of iterations and practice sessions with our pulmonologists and our pulmonology techs to see if we could split a single ventilator between two patients. As we were hearing, that was a methodology that was being used in China and in Italy to try and provide that much needed care for patients as long as we're severely compromised in the early phases of this first wave as it made its way across the country, and particularly in New York where we saw this was going on. I could go on forever, it's hard to stop telling the story because its just with us so long and it's still going on today.

Will Morris, MD:

Right. I think, one of the supply chain was I think... usually it's the unsung heroes and I don't think many people certainly as clinicians really understood the miracle that supplies up here on the floor, and that the nursing staff and the physicians have what they need always. And we are remissed to think, "Well, what really happens?" But out of this came a tremendous appreciation and awareness of the globalness of the supply chain and actually weak points. Going forward, manufacturing state side helps build resiliency, but are there other opportunities, perhaps leveraging the community for job growth creation? What are the other, I'd say, positive unintended consequences of sourcing locally and building redundancy and resiliency?

William Peacock:

Let me just tackle a little bit of that question first by describing what we saw happen. We saw our supply chain shook down and we were very concerned that distribution was going to be taken over by the federal government with regard to masks and gowns and gloves. And so we used our business analytics capability to start projecting out if under different scenarios, what would be our burn rate? What would be our demand? We actually did modeling with GoPro cameras on some of our clinicians heads and our nurses and caregivers in ICUs. What can we do? How many sets of PPE will we burn through in a COVID inundated ICU any given day? What would that number be? And we actually figured it out for several modalities. How many sets would we burn through in a COVID emergency department? How many sets would we burn through in a COVID regular nursing floor? How many in an intensive care unit? How many in an imaging location, where we're trying to shoot somebody's lungs?

William Peacock:

We came up with all kinds of adjustments and iterations and tried to be very precise with those numbers so that we could project out under different exposure scenarios what we would need. That was important first step, figuring out the demand. Then we began looking at, well, what can we buy? If we can't buy it, what can we find in the market that can be donated? If we can't get it donated, what can we make? This is where we work really closely with the state. With the innovations group, in fact. We went with our partners in Ohio, with a big company called MAGNET, to look for local manufacturers that were ready to turn production lines into mask makers, into face shield makers, right? I already mentioned earlier into a ventilator splitter.

William Peacock:

So those partnerships were absolutely amazing. And of course, we got besieged with well-meaning individuals who had a channel to some source of supply from a friend of a friend of a friend. But we were always worried about the safety and the efficacy of those products first. We had to insist on sending us a sample. "Let us try it on. Let's make sure it's safe." I think the other thing that we looked at very hard was disinfection. In this state, we had a couple of different approaches, for prolonging the ability to extend an N95 mask, a place where fortunately in this market we never had to utilize. We looked at both ultra violet and hydrogen peroxide sterilization methodologies to see if they would kill COVID viral load that might be present on these types of things.

William Peacock:

We even went to the point of building out a sterilization facility for N95 masks at our laundry facility in nearby Collinwood Ohio. Because we knew that we really got an extremis, that we were going to have to be turning these masks back. We set up a line, we were going to hermetically seal these things in shrink wrap to give caregivers confidence that a reused mask would be safe for use. So those are just a few examples of the things we did. I think we learned an enormous amount about the capabilities of our community, the eagerness of our partners to support health care and the capabilities within the state. I think all of us in healthcare have probably come away at least from this first year, I think we're still early in a second year of this pandemic.

William Peacock:

But I think we'd come away with a greater appreciation for looking beyond the distributor and looking at the source. I know firsthand that there are companies here in Ohio that are getting into the non-woven masks, that are getting into the gloves and gowns. Will these businesses be durable? Will they be sustainable? I think our distributors will be part of the equation of resolving that because they'll have to figure in the higher costs of manufacturing and how they make their margins. We as providers may look at buying a certain cohort of our supply demand locally so that we can have that assurance that we've got a durable inventory in the event of another pandemic or in successive waves of the one we're in right now. So those are sort of the things that I think about and our supply chain team thinks about very hard as we go through what I hope is the backside of a third wave in our Northeast Ohio market.

Akhil Saklecha, MD:

I'm curious about data. So one of the things you brought up when you were discussing medical operations and the actual operations behind the scenes, you mentioned international data, right? So understanding what's going on whether it's in Italy or some of our other facilities. I imagine that, and this is more of a guess, that the initial intent of viewing that data was more around the financial operations. But was that your perception and do you see that evolve more towards the medical operations, meaning capacity and supply chain taking more importance as you've described. And how did you see the IT infrastructure adapt out of necessity for sharing that data globally, right? Especially as it impacts preparation here in the States.

William Peacock:

So the image that's clear in my mind, Akhil is a command centre meeting where Dr. Conor Delaney, now our president down in Florida had Italians from Florence, Italy on the phone, and they were describing their ICU. It was more directed towards what type of clinical techniques are being used to manage these patients. And we heard about things like proning and we heard about use of steroidals, and we heard about other means, and we heard about what the presentation of this Polarized glass in the longest on CT scan. It was really basic down and dirty clinical treatment discussions at the medical operations level in the first early conversations internationally. Then it shifted to work force durability and resiliency. Then from there it shifted into protecting the workforce.

William Peacock:

So those discussions of being part of them led me to talk to our team in operations and start to do the forecast modeling that was necessary to make sure we had the necessary pharmaceuticals. So inside supply chain is a group that supports our pharmacy team. Pharmacy is actually a part of medical operations, but we were all one team one fight here. And so they started particularly for patients that needed ventilation. The paralytic drugs was an important thing for us to track availability of as well as steroidals. Then we became concerned about blood utilization. So tracking blood and forecasting blood availability forward. Up until this pandemic we're very good at looking at historical record and par level utilization.

William Peacock:

But this pandemic forced us more than ever to think like a Navy guy does when he goes out on a ship for 60 days or six months. What's going to be the burn rate of mine fuel and my food and my water, and that translated into what's the burn rate of my masks, my gowns, my gloves. What's the utilization rates on my ventilators, on my ECMO machines, on my dialysis machines. So those were the things that we charted. And honestly, we started looking in the early days anyway. We used a metric or rubric that you would've seen on any of the major television news stations. We use the rubric of social distancing. Assuming 30% social distancing, 50% social distancing, 90% social... do you remember those curves?

Akhil Saklecha, MD:

Yeah.

William Peacock:

They were all parabolas. The height of those parabolas was directly proportional to a social distancing assumption. And that drove the height and the altitude of that parabola. That parabola would correspond on to bed utilization, it would correspond to ICU utilization, and regrettably it would also relate to mortality. So using those models, we came up with different burn rates over 90 days, over 120 days, over 30 days. And we began a process of buying up to a 90 day supply, because we believed... We didn't know how many of these parabolas we were going to go through. How many of these surges we were going to go through. But we knew our state in particular issued an edict to cancel elective surgeries. So hospitals in Ohio would not consume more protective equipment than their healthcare providers could don and doff to treat patients. Well, you're bringing back a lot of memories with this line of questioning.

Will Morris, MD:

Well, hopefully good. I mean, what I'm hearing, and again, I hope those listening, I mean, the degree of collaboration and the passion in which we all share the same North star, which is how do we serve the patient and the community. But with such diversity of experience and humility, it doesn't matter where you are or what you're doing if we all have that same mission and serve, what a tremendous capacity? Looking forward, I would imagine the logistics conversation, the supply chain conversation continues with vaccination. What are your thoughts? You're sitting down perhaps in front of the new president, Biden. What are the roles of the individual health systems, the state, the federal government? Or learning logistic experts from business sector, even military, how do we continue to Akhil's question, the shameless exchange of data and information to raise the bar?

William Peacock:

One of the things that's so impressive is our CEO meets regularly with the CEOs of what would normally be considered our competitor hospitals in this market to have discussions. And most recently, those discussions have been exactly on this topic about vaccination. The vaccines are being distributed in vials to all of the healthcare nodes, the healthcare systems in Ohio. But think about this, there's about 11 million people in Ohio and the governor, if you just look at the next four weeks in front of us, will probably have about 100000 doses allocated to him. The state only gets about 3% of the vaccine doses based on the population of the state of Ohio. And then the state has to make an allocation to the hospitals.

William Peacock:

When we look at the Cleveland Clinic, we got about 3% of the governors, 3% that he got. So what does that mean in numbers, Cleveland Clinic getting about three to four thousand vaccines a week. Somewhere in that range. The governors control the distribution. And when the vaccines were first in receipt of their emergency use authorizations, the direction from our Ohio governor was to vaccinate healthcare workers only. So that's how we began. And we roll through our entire population using the help of our MyChart app to schedule appointments for healthcare providers. And we set up a single distribution site initially, because we were concerned about maintaining the chain of thermal control over these mRNA based vaccines.

William Peacock:

Hopefully and now currently we've set up vaccination sites around the system, five of them to be precise for our particular platform here in Northeast Ohio. We watched the governor in the state of Florida, where we also operate open up vaccination to 65 and older patients. Very quickly and very rapidly, which caused a run on healthcare providers down in the Florida market. Our governor elected here in Ohio to open it up to 80 year olds and above just as recently as Monday. So we began that course of treatment, and we had been working our way down the list of patients that we serve from 90 and above, and then every day incrementing down to 89 year olds, 88 year olds, 87 year olds working our way down the list. I don't have today's numbers, but I know, I think Tuesday, we saw about 23% uptake on the 90 year olds.

William Peacock:

And I know we got through all of our 90 year olds yesterday, and we'll continue to March down the list. It's interesting to be a healthcare system with global presence because we get to listen to Cleveland Clinic, Abu Dhabi and that market, not just their expense with the mRNA based vaccines from Moderna and Pfizer, BioNTech, but we get to listen to their experiences with the Sinovac and with the sour use, or the Sputnik, the Sputnik vaccines. So we're getting you hear what the uptake is both on the patient side and on the caregiver side with those single dose dead virus vaccines that are produced in those markets. So it really, I think, adds to the texture, the understanding.

William Peacock:

I'd be remiss if I didn't mention two other groups at the clinic besides just supply chain. I have to mention our infectious disease group which has been locked onto this since the beginning and the inception and an incredible partner to us in the supply chain and operations. And I have to mention the Lerner Research Institute, which has studied this virus, tested this virus, contributed to the science around the virus and been incredibly engaged globally in determining all of the aspects of transmission and impact and symptoms and reaction to vaccine, et cetera, they've produced amazing content to the medical space on this.

Akhil Saklecha, MD:

So, Bill, I think we could talk about our reaction to the coronavirus pandemic too. It's a lengthy conversation in and of itself, but I wanted to switch gears a little bit. You happen to be an integral member of our commercialization committee, which really is around new company formation and investment committee for startups. So you're in a pivotal role for how we support innovation towards commercialization and getting the invention and IP generated at the clinic out to patients. How do you view the Cleveland clinic support of startups and in particular the startups that we have going forward? Because it's such a cornerstone of who we are in our DNA.

William Peacock:

I think it's an incredibly important part of our mission, our vision, and what we value here at Cleveland clinic, which is innovation. Being a part of this team, it evaluates these opportunities. It's truly an honor. It's humbling to see the thought processes and the partnerships that are formed, and the opportunities created to try and improve care for patients through either the use of mechanical devices or interventions, or digital plays that might increase or improve patient care, or give ease to patient care.

William Peacock:

Being a part of that committee you get to see both sides of that world. I'm encouraged that our physicians want to play in this space. They want to make a difference. What really always amazes me, that they find time to do this with their education and their patient care roles as well. That they are able to carve out time for innovation, I think it's an important part of the clinic, and support commitment we make to them. So I'm glad to be a part of it.

Will Morris, MD:

Well, I want to be respectful of time because you are tremendously busy and we want to be respectful of your time. To that end we want to thank you because despite... I mean, an unbelievable oversight in terms of the operation or global operation, whether it be protective services, we talked about supply chain information technology, you have time to sit back and hear from the innovative frontline caregivers, researchers, clinicians, nursing, what are they thinking and provide that insight.

Will Morris, MD:

And I think at the end of the day, that is a true testament to you, your team, your constant partners and collaborators. While this has been a tremendous year for the books, I also think it is a bellwether of how... our most important asset is how we collaborate, communicate, and really think creatively for the future to come. So thank you very much for your time. And we look forward to continuing this dialogue. Thank you for listening. This is Will Morris with Health Amplified. The Cleveland Clinic podcast.