As the medical director of the Medical Intensive Care Unit at Denver Health, Dr. Ivor Douglas knows better than most how devastating a toll COVID-19 has taken. “We’ve lost 400,000 people, which is as many Americans as were lost in the Second World War,” he says. (The number topped 520,000 in early March.) “And we’ve done it in a year.”
At the same time, Douglas understands that the unwelcome arrival of the novel coronavirus presents an opportunity to advance health care at an unprecedented rate. “Absolutely it’s going to have long-term effects on human health and scientific discovery,” Douglas says. He believes such rapid progress will occur because, well, he’s seen it happen.
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For about 20 years, Denver Health has been treating acute respiratory distress syndrome (ARDS)—when fluid builds up in the tiny air sacs in the lungs, limiting the air they can hold—by rotating ventilated patients from lying on their backs to the prone position, on their stomachs, for prolonged periods of time. Although the practice seems counterintuitive (doesn’t breathing on your stomach appear constrictive?), Denver Health and other hospitals believed the practice increased oxygen levels while decreasing ventilator-induced lung injuries. But because there hadn’t been a consensus on the effectiveness of the procedure, and it’s cumbersome to move intubated patients from supine to prone (three to six people are required), few hospitals regularly performed the technique.
Then COVID-19 began causing ARDS in severe cases. A number of studies promptly affirmed that “proning” such patients was a potentially life-saving decision. Further, research co-authored by Douglas lent credence to the safety of prolonged proning, in which patients remain in the position for days at a time—more than 20 in some cases. Once the pandemic is over, doctors around the world will use that information to treat people suffering from ARDS caused by bacterial pneumonia or viral influenza.
Similar COVID-19-spawned symbioses are not rare in Colorado. Rival health systems have banded together; thousands of patients have donated their DNA to scientific research; and specialists have rebuilt relationships with community doctors. While the trauma of COVID-19 will endure for years, its lessons could inspire benefits that last for generations.
Building the Network
When confusion reigned, Colorado’s largest health care providers united to chart a course through the pandemic.
When COVID-19 first arrived in the United States, the Centers for Disease Control and Prevention advised that Americans who weren’t sick didn’t need to wear masks. Back then, even experts didn’t understand the best ways to combat the disease. “No one knew what was going on,” says Dr. JP Valin, chief clinical officer at SCL Health, and that includes the health care providers of Colorado’s seven largest hospital networks. “So we just said, ‘Let’s work on this together,’ ” Valin says. Physician executives of SCL Health, UCHealth, HealthOne, Centura Health, Denver Health, Boulder Community Health, and Banner Health began meeting virtually every weekday (and some weekends) to share data, discuss best practices, and manage the local distribution of personal protective equipment. By the end of July, the networks had collaboratively cared for 98 percent of the COVID-19-related hospitalizations in Colorado, and according to a study about the partnership published in the New England Journal of Medicine Catalyst, they boasted lower mortality, lengths of stay, and mechanical ventilation rates than the national averages. The collaboration later became a model for other states. “We can’t lose this after the fact,” Valin says. “This is something special, and we’ve done some really cool things.”
The Four P’s of the Pandemic
How the rival networks worked together to ensure Coloradans got the care they needed during COVID-19.
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Perspective: Before the state instituted a COVID-19 tracking system, the partnership recognized early outbreaks. In March and April 2020, Banner began seeing a spike in positive tests in Weld County. When UCHealth’s hospitals in Weld reported a similar flare-up, they traced the surge to patients’ employer: the JBS USA Greeley beef plant. The group notified the state and county, which closed the plant (although a Denver Post story questioned the speed with which Weld responded).
Patient advocacy: Many hospitals and clinics in rural areas are affiliated with a larger provider—but some are not, and more than 60 percent of U.S. rural hospitals don’t have a single ICU bed. So the collaborative worked through the Colorado Hospital Association to set up partnerships between rural hospitals and larger ones. The relationships included dispensing advice and accepting patients if they required emergency care. “In 48 hours,” Valin says, “we were able to quell a lot of unease” in rural areas.
Partnership: When hospitals were allowed to perform elective surgeries again in late April, SCL Health developed an algorithm to assess the health of incoming patients, and it shared this with the other systems. “So every patient in the state of Colorado who was getting an elective procedure followed that exact same protocol,” Valin says, “rather than patients and doctors being confused [about precautions], or one hospital being safer than another. We wanted there to be confidence in all of us.”
Peer support: An unexpected benefit of the partnership was the partnership itself. Physician executives are often isolated from their peers (both from other doctors and other C-suite suits). Through working with execs at other systems, they enjoyed support, workforce development ideas, and, in late August, a happy hour. “We went to the Lowry Beer Garden, where it’s all these picnic tables,” Valin says. “There was a lot of trust generated very quickly because we could say, ‘We’re doing the right thing.’”
Bridging the Divide
Children’s Hospital Colorado’s virtual town halls became a must-listen for a pediatric community that needed healing.
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For most of Children’s Hospital Colorado’s 113 years, community doctors tended to the facility’s patients. But as the economics of medicine changed, fewer physicians could afford to leave their practices to spend time at the hospital. Specialists became primary caregivers for inpatients. As a result, says Dr. David Brumbaugh, chief medical officer of Children’s, the hospital’s relationship with the local pediatric community grew distant. Then COVID-19 struck. To help terrified local doctors who needed concrete answers, Children’s began hosting virtual town halls. Eventually, about 500 providers began tuning in on Thursday nights to listen to Children’s docs review the latest science. The fringe benefit: The town halls began to rebuild the connection between the hospital and community providers. We spoke with some of Children’s most avid weekly audience members to hear how.
Dr. David Brooks | Valley View Hospital, Glenwood Springs
“We reached out to Dr. Sean O’Leary [a pediatric infectious disease specialist at Children’s] and he presented a Zoom conference [on virtual learning] to about 200 people in the Roaring Fork Valley. After that, pediatricians here helped re-establish in-person learning. I’m not sure we would have progressed to that point without the town halls.”
Dr. Sharisse Arnold Rehring | Kaiser Permanente, Denver
“I think I personally received several face shields from Children’s in the mail because I didn’t have any, and I wasn’t sure we were going to get them at Kaiser Permanente. We did, but Children’s Hospital didn’t ask any questions except, ‘What’s your address?’”
Dr. Sharon Sagel | Southeast Denver Pediatrics
“At the beginning you felt like this very small fish in this really big pond. How do we practice? We felt like we were reinventing the wheel every day. And then all of a sudden you’re connected to a whole community of pediatricians who are all in the same situation. I don’t know what the future will look like, but I think there is this sense that we’re all better when we work together.”
Dr. Matt Dorighi | Cherry Creek Pediatrics
“These town halls have certainly created the environment where you have that confidence to do new things, like telehealth. It’s such a great format for getting information on new ideas. It’ll be interesting to see what topics they shift to after the pandemic. But it’s been a really efficient way to affect change in the community.”
Even Bigger Data
Thanks to the telehealth boom, UCHealth’s Biobank connected with more patients than ever.
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Personalized medicine—also called precision or individualized medicine—tailors treatment to the specific indicators locked away in our unique DNA (and other molecules). The discipline could help improve the outcomes of pharmacology and even predict future diseases, such as breast cancer, based on cellular variances. In order for personalized medicine to work, however, it needs data. Lots of data. The more DNA collected, the more connections that can be made. The University of Colorado Anschutz Medical Campus’ Colorado Center for Personalized Medicine launched its Biobank in 2016 to become the repository of such info for UCHealth. It has since signed up more than 173,000 patients—but owes its biggest surge in outreach to COVID-19.
Biobank asks UCHealth patients to participate through the system’s online patient portal, My Health Connection. Before the pandemic, though, fewer than half of the network’s patients used the portal to, say, schedule appointments. When the pandemic forced UCHealth to switch primarily to telehealth visits, patients were suddenly required to use their portals—and, thus, interact with the Biobank consent form. “We’ve actually been able to reach out to more potential volunteers for the Biobank than we ever could have done before,” says Kathleen Barnes, director of the center. Which means a global pandemic could play a part in helping make Coloradans healthier than they’ve ever been before.
The pandemic has felt particularly isolating to new parents. Maybe that’s not such a bad thing.
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In August 2020, three months before she was due, Aliesa Pope-Hodge gave birth to her second son, Reign, at the Medical Center of Aurora. Weighing one pound and eight ounces, Reign was immediately placed on a ventilation system that filled his underdeveloped lungs with about 360 breaths per minute. “He looked like he was vibrating,” Pope-Hodge says. She estimates she got to see Reign for 20 seconds before hospital staff ushered the baby into an ambulance for the 10-mile trip to Presbyterian/St. Luke’s (PSL) Medical Center’s newborn intensive care unit (NICU), a Denver facility qualified to serve the most acutely ill infants.
There, Pope-Hodge and her husband, Diamond Taylor, donned masks, scrubbed and washed their hands, and were screened for fevers every time they visited Reign. Neither family nor friends were allowed to join them. But the restrictions were nothing compared to Pope-Hodge’s own feelings of separation. While practicing skin-to-skin contact to encourage bonding between mother and child, Reign would often cry. His heart rate and oxygen levels would drop—a common occurrence for preemies experiencing touch for the first time—and alarms would shriek. “I felt scared to touch him,” Pope-Hodge says. “Like I was going to hurt him. Maybe I stress him out? I felt detached from Reign for a very long time.”
Detachment might be the official emotion of the pandemic—particularly for new parents. Even though nascent research suggests COVID-19 is uncommon in newborns, even among those with COVID-19-positive mothers, most local hospitals and birthing centers have restricted access during birth to the parents (or mom and one support person, such as a doula). Once a baby heads home, many doctors recommend limiting visitation there as well.
While this has thwarted the ambitions of cheek-pinching grandparents, seclusion hasn’t been all bad for parents. “You aren’t trying to cater to extended family and keep them updated,” says Dr. Anna Zimmermann, a neonatologist at PSL’s Rocky Mountain Hospital for Children. “It pares the experience down to the parents and allows them to just get to know their baby.”
Research on the benefits of pandemic-induced alone time is minimal so far, but one study did test its impact on familial bonds. During April 2020, 70 pregnant women in Ireland participated in a survey that sought to quantify the emotional effects of social distancing. Of those whose relationships with their partners had not deteriorated (only three had), 34.3 percent said they’d grown closer, 28.4 percent said they talked more, and 20.9 reported exercising together.
Pope-Hodge and Taylor finally brought a five-pound Reign home from PSL in November and promptly barred visitors—a difficult decree considering they live with Taylor’s mother. “She held him on Christmas,” Pope-Hodge says. “Other than that, she hasn’t touched him, which is really hard for her. She feels stripped of the gift of being a grandmother.”
The isolation, though, has allowed Pope-Hodge to form a connection with Reign that she never imagined possible at the NICU. “[Our eldest son] King had his grandma and his aunties, and everyone else around him that gave him love,” Pope-Hodge says. “With Reign, I feel proud that I am, with Diamond, the ones who are taking care of him. Everything that he gets is from me. I feel really proud of that.”
The Neighborhood Association
Confronting the connections between public health and health care in our local communities.
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More than any other disease, COVID-19 has drawn attention to the tether between social ills and physical illness. “The pandemic has just brought it to the fore in ways that, frankly, diabetes didn’t, kidney disease didn’t, [and] high blood pressure didn’t,” says Dr. Jandel Allen-Davis, the president and CEO of Craig Hospital in Englewood. To illustrate the connection between COVID-19 and public health issues, Colorado Health Institute (CHI), a Denver-based public health advocacy group, created a Social Distancing Index (SDI). CHI gave each Colorado census tract a score from one to 10 based on its comparison to other tracts in the state in three areas: population density, overcrowded housing, and proportion of essential workers. The index is the average of a tract’s three scores. The higher the score, the more vulnerable a tract’s population is to the spread of COVID-19—and, as noted below, a range of social inequities.
More than 40 percent of children under 18 in College View live in poverty, compared to 18 percent countywide.
The four U.S. census tracts that make up the Westwood neighborhood are all at least 80 percent populated by people of color.
The wealthiest tract in Denver County is in the Hilltop neighborhood (median household income: $209,000). It is 86.6 percent white.
This tract in the Montbello neighborhood is one of the 25 USDA-identified food deserts in Denver County, all but six of which have SDIs above the county median of 3.1.
According to the U.S. Department of Housing and Urban Development, the percentage of low- to moderate-income residents (those who earn less than 80 percent of the metro area median income) in this part of East Colfax ranges from 61.2 to 87.7 percent.
The per capita income in this tract is $26,341, about three-fifths of Denver County’s per capita of $43,770.
In the tract with the lowest SDI, only 4.7 percent of residents live below the poverty line, compared to 12.9 percent across the county.
Matters of Life and Death
Bioethicist Matthew Wynia speaks out about the mortal dilemmas of the pandemic—and how COVID-19 could forever guide our moral compass.
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Who gets a ventilator and who doesn’t? Should everyone be forced to wear a mask? Which demographics deserve to receive the COVID-19 vaccine first? These are the questions the pandemic forced Dr. Matthew Wynia and other bioethicists to wrestle with as they attempted to guide the health care system through a stark market of supply and demand. Director of the University of Colorado Anschutz Medical Campus’ Center for Bioethics and Humanities, Wynia not only advised on state policy, but also helped oversee the UCHealth triage team as it made critical decisions. In the early stages of the vaccine rollout in Colorado, 5280 spoke with Wynia to better understand how local hospitals came to some very difficult decisions.
5280: Were the choices about, say, who would get ICU beds already determined before COVID-19 came along?
Matthew Wynia: Not exactly. We had a framework because we’ve had prior pandemics—the 2009 H1N1 influenza pandemic had generated a lot of interest in these issues. But it hadn’t been adapted to COVID. So that was the initial work. Pull that off the shelf, open it up, and start making adjustments based on COVID. Very early on, we were already seeing that there might be a problem with blood clotting. Well, that’s not a normal problem with influenza. How does that affect the clinical decision-making?
How does it?
Those factors get put into your risk calculation for how likely a patient is to die if they’re really sick with COVID. Because if you think they’re going to die no matter what, you’re better off not allocating them scarce resources. Also, if you think they might be able to pull through if they don’t get the scarce resource, you similarly don’t want to put them on the scarce resource.
So if a patient has a history of blood clots, no ICU?
Well, I’d be careful about that, because there are about 30 things in our calculation.
This is a question typically reserved for supervillains, but how did you sleep at night?
I am famous in my family for being able to sleep anytime, anywhere. That’s my superpower. In March, for the first time in my life, I was tossing and turning, because we thought Colorado was going to get hit hard, and we were going to end up implementing our triage teams. The thing [we] do not want is the bedside doctor to be the one deciding who receives these resources and who doesn’t. Number one, your bedside doctor should be your advocate. And number two, the bedside doctor does not have great situational awareness of what else is going on around the hospital or the region.
Yeah, but that means you have to make that decision.
Yes, but based on better information than that individual doctor has.
Because of all the tough choices doctors had to make during the pandemic, do you think bioethics has evolved?
If we make good decisions that clearly prioritize equity, we could come out of this with greater levels of trust in the health care system among racial and ethnic minority populations that haven’t always trusted the health care system—because they didn’t have a lot of good reasons to trust the health care system. Watching leaders in health care really struggle with how to do this right, so that we don’t disadvantage this community, that can be a cohesion-building experience.