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Women Leaders in Medicine, Ep. 16

Influenza, COVID-19, RSV: The Triple Threat of Winter 2022-2023

04/18/2023

In this virtual roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Amina Ahmed, MD, Callie Dobbins, RN, MSN, Katie Passaretti, MD, and Lisa Davidson, MD, about influenza, COVID-19, and respiratory syncytial virus (RSV), distinguishing the symptoms and clinical manifestations, managing changing guidelines and new information, and staffing and capacity issues.

Additional Resources:

Amina Ahmed, MD

Amina Ahmed, MD, is the Chief of Pediatric Infectious Disease and Immunology, a hospital epidemiologist, and a well-published pediatrics infectious disease researcher at Atrium Health Levine Children’s Hospital (Charlotte, NC). 

Callie Dobbins, RN, MSN

Callie Dobbins, RN, MSN, is the Senior Vice President for the Atrium Health Children's service line and the Hospital Executive for Levine Children's Hospital, Jeff Gordon Children's Center (Charlotte, NC). She is advising teams of hospital leadership to address the recent respiratory infection outbreaks.

Katie Passaretti, MD

Katie Passaretti, MD, is the Vice President and Enterprise Chief Epidemiologist at Atrium Health (Charlotte, NC). She has received local and national recognition for her efforts in leading complex health systems during the early years of the COVID-19 pandemic.

Lisa Davidson, MD

Lisa Davidson, MD, is the Antimicrobial Support Network Medical Director at Atrium Health (Charlotte, NC). She is a national leader in antimicrobial stewardship efforts through the Infectious Disease Society of America.

Jaspal Singh, MD

Jaspal Singh, MD, MHA, MHS, is the Pulmonary Oncology and Critical Care Education Medical Director at Atrium Health Levine Cancer Institute (Charlotte, NC). 

 

TRANSCRIPTION:

Jaspal Singh, MD:

Well, welcome everybody. On behalf of Consultant360, I'm Jaspal Singh, the host of Women Leaders in Medicine, a podcast series through Consultant360. And with us today we have four distinguished speakers, so I'm very pleased to introduce all four of them. I'll actually have them introduce themselves, and I'll start with Dr Passaretti. You're on my screen first.

Katie Passaretti, MD:

Great. Thank you for having me and super excited to chat with this wonderful group. My name is Katie Passaretti. I'm an adult infectious disease doctor. I did my training at Johns Hopkins and then came to Atrium Health about 11 years ago. My current role, I act as vice president and enterprise chief epidemiologist. So I have done a lot with Covid over the past couple of years and have acted as a resource within Atrium and outside of Atrium to the community for information on Covid and other infection prevention issues.

Jaspal Singh, MD:

Great, thanks. And Dr Passaretti, just like all our speakers will be going on a first-name basis from here moving forward. So Katie, thank you so much for that. Next, I have Dr Ahmed. Amina?

Amina Ahmed, MD:

Thank you. Thank you also for having me. I'm Amina Ahmed. I'm the Chief of Pediatric Infectious Diseases and Immunology at Levine Children's Hospital. I've been with Atrium Health for about 25 years. That's 25 influenza and RSV seasons that I've been through. And then T-minus one year in 2019, I took over the role of a hospital epidemiologist and broke my teeth on Covid-19. So I'm happy to be here. Thank you.

Jaspal Singh, MD:

Thanks. And I apologize for mispronouncing your name. My good friend was named Amina, so I keep having that mental block in my head. So, Amina thank you so much. Lisa? Dr Davidson?

Lisa Davidson, MD:

Hi everyone. Thanks for having me today. My name's Dr Lisa Davidson. I'm the medical director for antimicrobial stewardship in the Greater Charlotte region here. What are we calling ourselves these days? I'll go with Atrium Heath still. In my role as medical director of antimicrobial stewardship, I have worked with the team here on all things treatment, and even before we began with Covid, we had a lot of work going on in the system around appropriate antibiotic use, particularly around flu season and when you need an antibiotic. I've been with this system here since 2012, so for a little over 10 years. Before that, I was at Tufts University for a number of years. So, happy to be here.

Jaspal Singh, MD:

Well great. It's great having you. Callie Dobbins, thank you so much for joining us.

Callie Dobbins, RN, MSN:

Thank you. And I, too, am really excited to be with this esteemed group of ladies. So, I am not a doctor, that's where I'll start my introduction. I'm actually a registered nurse but have had a lot of roles in children's healthcare, specifically at Atrium Health Levine Children's. I've been here almost 22 years. So, Dr Ahmed has three more influenza and RSV seasons on me than I do. I am, however, 22 strong, and certainly not any of them like this year. But I did my training at UNC Chapel Hill and joined Atrium Health and Levine Children's and also have a couple of roles on the Children's Hospital Association nationally, looking at quality, safety, and actually our Covid response nationally. So, really excited to have part of this conversation.

Jaspal Singh, MD:

Well, that's fantastic. So, obviously, all four of you have this incredible amount of influence and a lot of depth and breadth here, so that's great. Obviously, the topic of today was the idea of influenza, RSV, and Covid-19. Some people are terming the quademic, which they add social and mental health and the strain of the workforce on top of this. It's become quite an ordeal. So let's start focusing on the viruses first themselves and sort of talk to us about, let's look at the three, RSV, influenza, and Covid in terms of clinical manifestations and symptoms. When people get sick and a lot of us have coworkers out sick, family members out sick, how do we distinguish between those three? Is there a way to do it or are there some similarities? Or walk us through the clinical aspects? I'll start with Dr Passaretti.

Katie Passaretti, MD:

Yeah, so unfortunately the symptoms of Covid-19, RSV, influenza and a bevy of other respiratory viruses are largely similar. All can present with fevers, runny nose, cough, and congestion. Back in the early days of Covid, that loss of taste and smell was kind of one main way if present that you may be able to distinguish Covid from other respiratory viruses. But as the pandemic has evolved, as we've seen different variants, we're seeing that less and less frequently. So really, you can't tell from clinical presentation which virus it is. Certainly there can be epidemiologic clues, right? You are exposed to someone with Covid, you are exposed to someone with RSV, the age, that kind of thing may give you hints, but just based on someone coming in de novo, there's just, unfortunately, no great way.

Jaspal Singh, MD:

Great. No, I agree. And then Amina in the pediatric world, talk to us a little bit about that space a little bit, if you don't mind? What the symptoms look like for the kids and the adults, maybe some age differences and things that we can look at.

Amina Ahmed, MD:

Yeah. So like Dr Passaretti said, it really has become very difficult to distinguish between these viruses. I used to pride myself on being able to tell from across the room who had RSV: the kids who were snotty, the kids wheezing. I could tell, this is RSV, you don't even need to test for it. And we spent a number of years training people that you don't have to test for RSV because you're going to treat them the same anyway. And now with Covid, we learned last year the importance of testing for viruses, right? It became very important for Covid 19. So RSV is a pediatric disease. Typically everyone has had it by the time that they're two years of age. It's a rite of passage. Everyone has to have it. And immunity is unfortunately not complete. So you continue to get it throughout your life, even as an adult, but it just becomes less and less severe.

The worst case of RSV I ever had, and I know it was RSV because I gave mouth-to-mouth to a baby with RSV, and I had a horrible cold, but I didn't start wheezing. I didn't end up in the hospital like young babies do. So under two years of age, you're going to get it. And then when you do get it, if you're under six months of age, those are the kids that get into trouble because they have smaller airways. So that's how you kind of tell RSV in babies under six months of age, wheezing, lots of mucus involvement, et cetera. For influenza, we've learned through the years that really it's that school-age kid that are responsible for really spreading the epidemic every year-so any child under five years of age. We do go on these ILI- influenza-like symptoms that we use; and they need to have a cough and a fever and they need to have some sort of other symptom- myalgia or sometimes they even have GI symptoms.

You can kind of tell that. But unfortunately, Covid-19 has all these right? And Covid-19 can affect babies and Covid-19 can affect the school-aged kids. So really what we're trying to do is see if we can test for the things that you know you're going to intervene with. Covid-19: you're going to intervene because you want to prevent them from spreading it. And with influenza, you're going to intervene for the high-risk kids at least, or the high-risk adults at least with Tamiflu. So testing should be limited to when it's actually going to make a difference. And for RSV babies, I would argue you can still probably tell without testing. Covid-19 has been really an anomaly for pediatrics. It hasn't affected a lot of kids and kids have mild illness. So usually the babies, you can tell if they have anything symptomatic is going to be RSV.

Jaspal Singh, MD:

That's very helpful. So I think the testing part is really important and I think I'm going to ask Dr Davidson to comment on the testing part. If you're like my family, Lisa, everybody wants you to call in antibiotics, they want you to call in a Z-Pak or something else like that. And so tell us how you counsel for adults in terms of testing and when to test, how to test, and how often.

Lisa Davidson, MD:

Yeah, so I think that diagnostic stewardship, as we like to call it, has really started to play a much bigger role than it had in the pre-Covid times. Before Covid, we really would just say if it's influenza season and you have influenza symptoms, you really don't need to test because you've got the flu and we'll treat you if you're high risk. But that is not the game anymore. The game has changed with Covid because as Amina said, we have triple or quadruple threats. And I think the next five years are really going to see a big change in primary care and how we decide to address our testing. So I think there's a big difference between an inpatient and outpatient. When someone comes into the outpatient office, we test for Covid because we've gotten super used to testing for Covid over the last couple years.

And I think the question is going to be, how long do we continue to do that? And I think Katie or Amina may have some comments on that as well. As it becomes more endemic, it's a little different than influenza because there's a potential for long Covid and other complicating symptoms so we do want to know. But if you're an otherwise healthy person, it kind of doesn't matter if you have Covid or RSV or influenza, it's the same thing. You want to stay home, you want to isolate, you probably want to wear a mask, and really restrict yourself around people who are high-risk and immunocompromised. The flip side of that is patients love a test, that patients want to be tested. Unless it hurts, if it hurts, they don't want to be tested. It was uncomfortable, but boy, everybody wants a- test. So you have to strike this balance between the, will this information be useful, will it change behavior?

And then the cost. Because the other things that I always encourage a frank discussion on is, you go into urgent care or you go into your primary care doctor's office and you're asking for all these tests, it's expensive. And at the end of the day, you're charging several hundred dollars for something that didn't need a test and certainly didn't need an antibiotic, to begin with. So I think the real issue over the next couple of years is who are we going to test?

So, certainly today we continue to do a lot of Covid testing. I think that's super appropriate. I think as Amina said, for influenza in adults or RSV in adults, we have limited ability for testing for RSV, we tend to test that more in patients who are high-risk and immunocompromised. And for the flu, we do have flu testing available and the question is whether that's even needed or not. So again, that's probably a discussion between the care provider and the patient, risks and benefits. Would treatment be indicated? In most patients, treatment for influenza really is not shown to be effective after the first 48 hours of symptoms. So again, is it really going to make a difference?

Jaspal Singh, MD:

That's great. So, just to wrap up the first section of this. It sounds like the symptoms overlapped quite a bit. They're almost hard to distinguish almost. You have some clues both in adults and kids, what it might be. But then again, then comes confirmation of testing is helpful. But again, I like the term diagnostic stewardship. I don't think I've really sort of doubled down on that. I think I'm going to use that from now on, just to sound smarter than I actually am. And I think that will be a good term moving forward as we learn more and have a lot of unanswered questions. Did I miss anything else?

All right, then I'm going to sort of fast forward. So this has been quite an ordeal for, all around the country, just as we came out of Covid, then we had the staff burnout crises, we've had staffing issues throughout, and then chase that now with the RSV and influenza sort of threats, and now Covid resurgence in some parts of the country. So obviously all of us know, people have been hearing, I think most of us are kind of probably ignoring some parts of the country that are really struggling in terms of volumes and acuity both in adults but especially in the pediatric area. So Callie, talk to us about what your role has been trying to work out the logistics here a little bit. What are you seeing, what things are happening now, both locally but also nationally?

Callie Dobbins, RN, MSN:

It's interesting that we find ourselves nationally at a place where children are under-resourced for beds. For the last 10 or 12 years, systems have been either doing one of two things. They've either been consolidating their pediatric beds or they've been closing them. And not surprising as to why. The economics in pediatric healthcare is at best not great. And so if you can't get scale and scope, systems were sort of facing with, we have demand in adults, we don't have as much demand in children, so let's close these beds. And we had early warning of will Covid be the tipping point. Gratefully and thankfully it really wasn't. We were really able to manage the initial surge of Covid pretty well in children until early fall. And then as we've already talked about the rationale of why we've been seeing high rates of respiratory conditions, we felt it in the southeast a little earlier than some of our other places nationally, who are now reporting it currently.

But what we found is that we don't have enough beds and we certainly don't have enough critical care beds, and we have no way to coordinate. And so when you find yourself in a place of under-resourced, undersized, and no way to coordinate, it's sort of the trifecta for potential crisis and chaos. So in North Carolina specifically, we took our early warnings of high ED visits, pediatricians, and family medicine practices who were consumed and certainly not going to be able to keep up with demand. And then the downstream of hospitalizations being high to try to find a way to coordinate ourselves. And so we have done some of that, and we've been sharing that work nationally on how are we trying to coordinate ourselves so that every child who needs a bed at least can find a bed. It's the first time in my history that we've ever sent children out of state, but we had to because it was the best place at that moment for children.

And so now we're in this, I've been telling our team, we're in this sort of pause to be ready for the next. And so what did we learn in the first surge that we need to do differently? Some of those things have been doubling down on access in our primary care offices. We're fortunate in Atrium Heath that we have 35 pediatric primary care offices and a multitude of family care practitioners in our community, who needed to provide access on weekends, needed to provide access in after hours, and needed to double down and have triple booked appointments.

None of which anyone likes to do, but it was a must-do. And so we've been implementing those strategies. We've implemented early triage. Mostly, as Dr. Davidson mentioned, people just want a test. And so if we can get people to know you actually don't need to be, it's okay to be sick at home. Most of these parents with these young kids haven't experienced a child that's ever been sick. And so they have this pent-up desire to go and get told they're okay. And so how do we provide assurance in the house so that you never use a resource has been another area that we are really double downing on. And increasing access to virtual visits as well.

Jaspal Singh, MD:

Wow, that's amazing. That's exhausting. Just thinking about triple booking nights, weekends, I mean just coming out of this and hearing you all talk about how much is involved here. I guess I never really appreciated the idea that these parents had really not seen young sick kids to that degree. So that's really important, I think that's an important message. So sounds like getting some public health messaging out there to stay at home, try to ride this out if you think that your child's not well. Amina, I'm going to ask you now how are you counseling your colleagues and other healthcare professionals on how to approach kids who are sick at home and how to approach warning signs that they need to go to the hospital or something like that?

Amina Ahmed, MD:

Yeah. So the warning signs would be the same, fortunately, no matter what the respiratory virus is, right? RSV or influenza or Covid-19. Certainly, I think it's important to educate families about the risk factors associated with severe RSV disease for babies under six months of age because they have smaller airways. If your baby is premature, if your child has congenital heart disease, your baby's going to be at higher risk for getting more severe disease. So then maybe your threshold for bringing that child in would be a little bit lowered for those particular populations. But the symptoms will be the same. Anything that really sets off their respiratory rate tells you that they’re having trouble breathing. Or, for the very young baby, it is actually trouble feeding, which is an indication that they’re having trouble actually breathing. And then the fever itself shouldn’t be a concern.

Fevers go very high with RSV and people are really like, oh, it’s 103, 104. It must be bacterial. No. RSV loves 103, 104 fevers. So it wouldn’t be the fever necessarily, it would be basically difficulty feeding, difficulty keeping up hydration, difficulty breathing, and those are the things they should bring you in. Otherwise we do try to teach parents, but I think they've gotten used to having the access to RSV testing. And the more that they hear about it on the news, the more they want to know for sure. But really it's not going to make any difference because the treatment for RSV is really symptomatic management for the most part. We're not going to give any specific breathing treatments, we're not going to use steroids. And so for most of these cases, and again for influenza, unless your child is at high risk, we're not going to treat any differently.

And by high risk, I mean having some sort of hemoglobinopathy or again, having some sort of an immunocompromised condition. So it's better for your child to stay at home and not, first of all be waiting in the waiting area. And second of all, not be spreading anything. So I think the message would be the same. And I think that the pediatricians and the family practice doctors are doing a great job of delivering this message as best as they can. And like Callie said, turning to virtual care, which fortunately we learned to do very well during Covid-19.

Jaspal Singh, MD:

That's great. That's very helpful. So I guess I'm sort of left to wonder from the perspective of an adult clinician, a lot of our audiences are adult physicians. What are the sort of most important messages that you want them to get at this point? The adult non-infectious disease experts? What are the take-home points? Lisa or Katie, one of you can start and take turns?

Katie Passaretti, MD:

Sure. So from my perspective, I focus mainly on prevention. So I think the message, whether it's for flu, Covid, RSV, spreading it to your family, spreading it to your friends, the ways you prevent are the same. So getting vaccinated for flu, Covid, unfortunately, there's not currently a vaccine for RSV, but those are broadly available. And we know particularly with the bivalent Covid booster uptake has been pretty poor. And because flu season hit so early this year and so hard, most people have in their mind, oh, I'll get vaccinated late in November around Thanksgiving before I travel. It's just really important. If you haven't gotten it, there's still an opportunity to prevent illness. Go ahead and get it. So vaccinate, vaccinate, vaccinate. We have seen the repercussions in healthcare, in our community, of not staying home when you're sick, whether that's Covid, flu, or RSV.

So I continue to strongly encourage people, when you're sick with a febrile respiratory illness, you're not doing anyone a favor by powering through. And that's true for healthcare workers. That's true... I know it's logistically tricky, but it's so necessary. And the reason that we saw less flu, part of the reason that we saw less flu, RSV, all the things during the past couple of years is that we implemented things like staying home when you're sick, more aggressively, limiting interactions with others when it makes sense. We're in a different point. I'm not saying lock everything down again, but I think, when you're sick, you need to stay away from other people and protect them while you're getting better.

And then masking does prevent the spread of all respiratory viruses, Covid, others. So certainly if you have to go out when you're symptomatic, if you knew you were exposed, if you're in a high-risk setting, I do. And we continue in our area to require masking in healthcare settings because we have such a high concentration of people that are very, very susceptible. So using those tools that we have, vaccines, masking, staying away from other people helps with all the respiratory viruses.

Jaspal Singh, MD:

Yeah. I'm having flashbacks, the Covid pandemic and-

Katie Passaretti, MD:

I know.

Jaspal Singh, MD:

It just seemed like a lot of the same stuff, it's just not going away. Lisa, anything else to add to that?

Lisa Davidson, MD:

Yeah, I like to say never waste a good healthcare crisis. And so I think the one message that consistently came out of the Covid epidemic is everyone to understand what a viral pneumonia is. People didn't really accept that beforehand. Like, oh you have a viral pneumonia, what's that? And so now with Covid, everybody understands that. And our physicians do an amazing job. But if you're asking me what's the message for an adult physician, we always talk about the good news, bad news, good news sandwich. You want to do some communicating with your patients to say, "Yeah, you're sick, you have a virus, but let me tell you what we can do to treat that virus." Maybe it's over-the-counter medications, hear how often you should take Tylenol or Advil, but an antibiotic won't help you because antibiotics don't treat viruses.

So we definitely want to get that medication across. I think the other thing that we have seen is that it really depends on, you have to have good communication with patients who are high-risk. And what does high-risk even mean? So in some communities that's patients with moderate to severe COPD, or it might be your an uncontrolled diabetic or it might be your frail elderly. So it isn't a one size fits all, but those patients also tend to get more steroids, more antibiotics, and at the end that's going to cause more harm than it is helpful. So what I really encourage providers to do with their patients is create a line of communication. I think we've done some amazing things in the system to use our different resources to do that. At the height of Covid, right? We had nurse lines dedicated to Covid care.

We don't have that anymore, but it was super helpful. But we do have availability, particularly through our televisits and particularly through virtual visits. I'm a big believer in virtual visits for upper respiratory tract infections because you can talk about your symptoms and then we can talk about home monitoring. So if you have high blood pressure, what's your blood pressure? Are your sugars out of control? All the things. If you have previously used a home O2 monitor, do you have one of those to check your oxygen? And then talk about when do you call back or when do you need to come into a visit? So as Amina said in kids, if you have 104 fever, we don't really... That's normal. That's what happens in kids. If you're an adult and you have 104 fever, that is a totally different scenario and you need to come in and need to be seen.

I think Callie would agree, we would rather have you seen in the office rather than in the emergency room. So keeping communication open and then actually giving patients identifiers of when to call back again, and when it's appropriate for symptomatic care versus treatment. The other thing that we always say, and I like to be thoughtful about is, if you've been sick and you got better and you got sick again, or you got sick and then you're much, much worse, that's when you really want to be seen by your doctor, particularly in the elderly or those with who are immunocompromised.

I don't know what's going around right now, but I've had lots of people come to me and say, "I've been sick for three weeks" or "I've been sick for a month." And whatever that virus is that's going around right now in the month of November, that virus is lasting forever. But so you want to keep tabs on it, but if you're not getting any worse then there's not going to be a reason to come in and get treated. So communication is the key to good treatment. We want to make sure patients feel supported, but we also don't want to overwhelm the system with unnecessary visits.

Jaspal Singh, MD:

Perfect. That's a great summary of that section and appreciate that. Callie, I want to come back to you a little bit. You mentioned a little bit ago about the communication piece, but logistics, what we learned in Covid, let's take some of that. What's the pediatric world doing compared with the adult world? And what are you doing differently? I'm just curious because I don't live in that space and we learned a lot. And we just sort of did an all-out assault on everything that might work, from staffing, nursing lines, communication, testing, and it was kind of a little of a circus, well-intentioned. But we've learned some lessons here, and some of the pediatric folks actually helped us in the adult world. And I'm wondering how that's looking now, now that we're in a different state.

Callie Dobbins, RN, MSN:

Well, I first would say I'm really grateful that our adult colleagues gave us this great playbook that we could use. So never waste a good crisis, to Lisa's point. We did a lot of the planning for Covid that we didn't have to use. And so honestly, a lot of the same strategies that are very familiar to our adult colleagues, we're using in children. I think the piece that we've been more proactive in is that, at least within Atrium Health, we have a large footprint in school systems. And so we're actually in about 90 schools across North Carolina and Georgia. And so that gives us an opportunity to be as upstream possibly as you can to provide support in a school system where most of these children are, perhaps not our infants, but at least our school-aged children who are spreading flu, to help them know when they need to go home.

Know you don't need to go to the ED, there's no additional treatment that needs to be done. And the way that program works is it's a virtual visit to a provider on site. And so early in this recent surge, we noticed that all these children on Monday morning were showing up to school not because they thought they should go to school, but because they had no access. And so we had two choices, we can make it difficult or we could say, "You know what? It's going to look like a little bit of an infirmary if we could figure this out with our principals." And we did. And now what I would say is in many of these locations, because they happen to be underserved healthcare areas, we've actually likely prevented a worse surge. And certainly these schools haven't had to close, which we've seen in other school systems.

So that's one unique thing we've done. We actually never stopped our nurse line, if you will. So Lisa referenced that earlier. We never stopped it, again, anticipatory guidance in families is triply important. Parents just want to know that what they're doing is right. And so we had not yet stopped it. And so what I've done is reorganize what all we're talking about. So we're not just talking about Covid, if you will, we're really just talking about what are your child's symptoms and what is likely needed next. And when do you need to call us back and when do you not need to call us back?

Fever is a trigger word in children. Everyone thinks a magic number means something. And so helping them talk through those things to reduce just overall access and demand. So those are two things we've doubled down on, and really trying to walk with families through this journey and helping them know that another test isn't going to help them. The other piece we're hearing a lot from families is that the fever's taking weeks to get through and that that's okay. And so again, that ability to have someone to call and not necessarily need to clog up our health system.

Jaspal Singh, MD:

Fantastic. I like the idea of working upstream as much as you can before the hospital. And educate and leverage the public health resources and community health resources that you can to get ahead of that. And so I think for the clinicians, for our audience, sounds like as much as you... If there's educational opportunities up ahead... may not be yourselves or if you're overtaxed, but maybe someone in your practice or office or community that you work with... potentially think of other ways to get the messaging out. I think that's fantastic.

Well, that's amazing. Now we don't have time on our podcast to discuss all the challenges of our staffing issue, the other part of the pandemic that we alluded to earlier. But I'm going to sort of allude to it by asking you all how you're doing. I mean this has just been exhausting. I'm exhausted. The Covid pandemic I think just pretty much hurt pulmonary critical care physicians across the entire world. And Infectious disease is right there. So twins in this space, but this has been tiring. And now everyone else is tired and we're having a lot of issues here. But first of all, how are you doing? And do you have any ideas of how we're going to get through this all together? Phase by phase? Start with Katie.

Katie Passaretti, MD:

Yeah, so certainly for me personally, the most challenging time of my career has been the past couple of years as far as dealing with unknowns, making sure we're trying to do the best during a time when information was constantly coming in. And then, more so, and even more so now is the impact on our colleagues, our teammates around us and watching that. And initially, everyone was all in it together, but that's really hard to keep doing, and people are exhausted. And we've seen good friends, colleagues that have made the decision to leave medicine. The staffing crunch continues to be hugely challenging to deal with operationally, hard for boots on the ground as we're seeing patients to get stuff done. So, I think it for sure has been in my career, my lifetime, the hardest time I've seen in healthcare. I do think there's hope out there, and I think there are some good parts that came from Covid that we need to remember and take forward with us.

That flexibility and adaptability that Callie has referenced time and time again during this talk, and the ability to switch things up and switch things down. We need to keep that in healthcare moving forward. We're going to continue to see infectious disease crises, all the things over the coming years. It was Covid, and flu, and RSV and we had monkeypox, and it's just been one thing after another and that's going to continue. So acknowledging that, being prepared for that and having those levers to pull that work for different situations will be important. And then looking for the stories of hope and the people that lean on each other. I think we've learned a lot about leaning. We're physicians and nurses and all the people in healthcare tend to be like, "Oh I'm strong and I can do this by myself." We have to lean on each other. And that's true. Adults in peds, within peds, within adults, that kind of looking for the hope, the good things and focusing on that and reminding people it's there when it's hard to remember.

Jaspal Singh, MD:

I think that's great advice. So that's good. Sounds like you're doing okay on your own.

Katie Passaretti, MD:

Yeah. I'm okay. I just got back from vacation, so right now I'm really good. But, you know, it varies.

Jaspal Singh, MD:

Amina anything to add? And how are you doing?

Amina Ahmed, MD:

I just got back from vacation too, so I'm doing great. It was our 25th wedding anniversary two years ago, so we finally celebrated it. So it's great. So yes, I mean just echoing what Katie said, it's been very challenging. It was very challenging for me because it was like, I joined hospital epidemiology and I was still on a learning curve and then all of the sudden it's like boom, it exploded. I think we were all expecting a pandemic, we just all thought it would be influenza and it wouldn't be coronavirus. And I have shared this with Katie and the rest of the infection prevention group, but apparently, about six or seven years ago I wrote an article on respiratory viruses. And in there I say, no one knows when the next SARS-CoV-2 pandemic will hit. And then, it just sort of foretelling the story.

I think I've learned a lot, I've been very amazed and I'll say this again to Katie, I was just amazed at how we stood up the testing, just the testing part for Covid-19. It's just amazing to me that we stood that up and got it going and it was efficient, and it was informative. And I think one thing I feel very hopeful about is that when the next pandemic does occur, that we'll be ready for that. And I think same thing with RSV and influenza, yes, nobody thought it would happen to this degree, but this was very predictable. We knew that people were isolating, people were masking, people were trying to keep from spreading infections. So we knew that RSV kind of stuttered along in 2021, it came up in spring, then went away and then came up in the summer, and then now boom it hit.

So it was very predictable. We just didn't predict that influenza would hit the same time. So I would definitely say, I think that I'm very hopeful with the next pandemic or whatever crisis occurs that we've learned our lessons and then we will certainly use these lessons. I will just add one thing, just because I went into infectious diseases because I was going to save the world with vaccines, right? I will add that you can't do much about RSV, right? The vaccine isn't here yet and you only get the monoclonal antibody if you're very high risk. But we do have a vaccine for influenza and RSV is sort of plateaued and may be hopefully decreasing or in the decline. But influenza has not shown its... It has not reared its head fully at this point. So do everything you can to get your community vaccinated. And so maybe we can sort of prevent some of this tripledemic, quademic, is that what you called it? From just sort of getting out of control.

Jaspal Singh, MD:

No, that's great. That's great advice. Lisa, I assume you're not coming back home from vacation also. Could that be true? That'd be like all four of our panelists, maybe.

Lisa Davidson, MD:

I'm going on vacation next week. You asked how I was doing personally, I think okay. I think one of the things we learned here is that we have to support each other, as Katie said. And we also have to recognize when there are times when we need to say, it's okay not to be okay. And I think as healthcare workers or when you're in healthcare you go and do it to help other people. And so it's very hard to personally take a step back or to see your colleagues not willing to step back, including some of the people on this call. I'm just going to say that. So it's important, I think... What I try to do, where I find I can be the most helpful sometimes is working with my colleagues when I see that they're suffering, or they're not taking breaks, if they're not doing well to sort of call it out and try to help them create boundaries. Because I think one of the things that happened very early on in the pandemic is we all became boundary-less for good reason.

I think, and Katie and I have talked about this as an infectious disease doctor and probably as a critical care pulmonary doctor, this is kind of what we were called to do. We were trained to do this and we went into action. We knew we had the tools or some of the tools to start doing the work. And while that was in some ways rewarding to a certain extent, it became exhausting. I think that potentially other members of our healthcare system were not as well prepared. And so that's why you see some of the burnout. But I think although the last couple months have been stressful, we've kind of been able to take the second half of 2022 and sort of regroup a little. There was some amazing stuff that happened, I just got the picture, it was like on your iPhone you get the pictures and I got the picture from two years ago when I got my vaccine, and I remember what a joyous moment that was because we felt like finally there was something that we could do.

But as Katie said, here we are two years later and we're begging people to get the vaccine. So I'm a little bit, I'm usually a little bit of a pessimist. So I feel like Katie's usually the optimist. So we work really well together. What I find frustrating right now or what I'm feeling frustrated by is that we've learned so much, but we're kind of trying to go back to the old way of doing things. We're prioritizing the things we prioritized before the pandemic, we move resources around and now we're like, oh we're back to normal. So we're moving them back to the way we did it before. And it's frustrating to me that we're not learning the lessons and really putting things in a completely different perspective and changing the way that we practice to meet the new reality, right? As Amina said, we're going to keep having these cycles, it's going to keep coming.

And we can't do it like we did it before because it's not going to work. And we've learned that, we're learning that with staffing and how we address staffing and burnout and the crises that we're having, how we're caring. We've talked about it a lot on this call. But I think globally in the field of healthcare and how we practice healthcare today, we're not seeing the shifts that we need to shift. And we're not seeing it either in how we communicate with patients. I'll say it again we have vaccines for two or three of these illnesses. Our vaccine rates are terrible. We need to figure out a different way to vaccinate our population, because without that we're really not going to... We're going to keep having these type of epidemics over and over and over again. So I think we need to look at how we practice healthcare and really reinvent things a little bit or take the lessons that we've learned and actually put them into place.

Jaspal Singh, MD:

So you can rest. Rest easier. Sort of take the lessons that we learned and not be frustrated. And I think we'd probably go down the whole rabbit hole about the information issues about who to trust and the public and the media and all that sort of thing. But we're not going to go there because I think it's just going to be overwhelming. But that being said, Callie, I'm going to come back to you about all the lessons you just heard and going back, and how are you doing and what are your salient messages here?

Callie Dobbins, RN, MSN:

Honestly, I am good and that's because I've been intentional about it. And I hope you've heard some of those intentional messages from the three ladies before me and that you do have to step away. This is not a series of mini sprints, it actually is a marathon. And while that's really cliche, I think many of us in healthcare are a little bit of adrenaline junkies at heart. And so you like your little surge, and I think what's happened is repetitive right? You know it's pathologic, right? You're not going to be able to get to the top of it every single time. And I think over time we've just gotten empty. And so I certainly had to be intentional about that, really at the beginning of this year said, I don't have any more energy left. I cannot go through one more surge, one more thing, one more crisis if I don't start taking care of me.

And I hope that those listening will really take that to heart. It's a new year. What a great time to be able to reset and really think about what it is that fills your bucket and how you really get to your inner why. It doesn't always have to be about our patients that we care for. There can be other things that we really care about. And so I think that's really important. The other thing I would just say is that when we talk about staffing, I think we think about it very much in a reactive way. We walk in and we're frustrated because whatever we expect to happen that day can't happen because we don't have the right people. That's as simple as you can boil it down. What I would say is, we have got to stop that conversation and really step back and figure out how do we change what we think about, as our traditional model of care.

We are great at talking about it, we say it all the time. We use really great cliches, but we actually have done it very rarely. But we did do it in some ways to Katie's point earlier, the things we were able to stand up in rapid order, all it took was someone raising their hand and saying, "I'm willing to go do that, I'll be a transcriptionist, I'll do..."

Whatever it was. We found ways to do it in Covid and I hope that we are going to bottle up some of those lessons and apply it to our staffing strategies, because if we keep waiting for more nurses, more providers, more physicians, more specialization, we're going to lose the battle. And so what I am trying to focus our team on is, what do we control in this crisis? And we control that. And so we can absolutely try some models of care, flexible schedules, all the things we talk about, actually try it. I do think that that will fill people's buckets. I think it'll allow people to have a little bit of time to recharge in between the surges or the crisis or whatever it may be. And I hope that it's our long-term play to reduce some of the burnout that we're all experiencing.

Jaspal Singh, MD:

No, I think that's really well said. I think all four of you just really hit home with a lot of the important points. I'm glad you're all doing well. That's fantastic. And I'm glad some of you guys got some time away and then Lisa, you got some time coming up, so that's fantastic. Callie, I think you can just call me anytime. I'll be working for a while here. But in any case, let's kind of wrap up. I think we've covered a lot. I mean we talked about the RSV, influenza, Covid-19, about how the symptoms overlap. We talked a lot about the testing, the diagnostic stewardship, which I like that a lot, that terminology quite a bit. Getting the messaging out there on prevention, as far upstream as possible. The idea of when to stay home and try to get people to stay home, leverage some of the additional technologies, whether it be home pulse oximeters, other technologies to sort of help monitor people.

Make sure that people who are susceptible or higher risk get proper attention when they need it, whether it be adults or kids. That right now there is this crisis and it's kind of... Sounds like from what I gather, we didn't discuss this, but it sounds like we're seeing nationally are trends in different geographic pockets of one versus the other virus. And depending on which population that you're dealing with and it can change relatively quickly. And so I think what Callie was talking about earlier was sort of not focusing so much on the individual viruses but actually focusing on the syndromes, and managing the syndrome, educating on the syndromes is probably really more important than necessarily picking any particular virus out unless someone needs specific testing required for certain populations but really affects treatment. And then the ideas of taking care of yourself, taking care of your staff, taking care of some time off, if you can.

And then work through all those aspects. And then hopefully it sounds like, as Callie was saying, a call to action. Some of you were saying a call to action about, let's revamp how we approach these things. Because this is just one of many, this may be a series of cycles and this may just be a marathon for the rest of our careers for many of us, in terms of how we manage. And it might ebb and flow in the adrenaline aspects of it, but it's going to be constantly things that we have to pay attention to. Did I miss anything else? All right. Well, on behalf of Consultant360, I just want to thank our guests today. You guys were fantastic and again, I'm sure our audience has a lot to learn from you all. So I appreciate this and best of luck with all of you.