It was late January, six days after officials in Washington state confirmed the first case of COVID-19 on U.S. soil and five days after President Trump said the outbreak wasn’t likely to turn into a global pandemic.
“We have it totally under control,” Trump told a CNBC interviewer while attending the World Economic Forum in Davos, Switzerland. “It’s going to be just fine.”
The date was Jan. 27, and inside a windowless basement conference room on the 500-acre campus of the Togus Veterans Affairs Maine Medical Center in Augusta, two dozen staff members took part in a tabletop drill simulating an emergency brought on by an emerging pathogenic coronavirus.
It was something the national VA pushed out, “because we were getting alerts that this was a situation that was occurring overseas,” said Kim Ware, associate director for facility operations at Togus.
Trained as an infection prevention nurse, Ware has been with VA Maine since 2007 and experienced the swine flu (H1N1) outbreak in 2009 that saw 2,232 Maine residents become infected and 21 of them die. A few years later, she dealt with the Ebola scare.
But long before she came on board, VA hospitals had battled infectious diseases such as tuberculosis.
“We’ve talked for years about what to do with a large pandemic,” Ware said. “That’s one of the great things in the VA – we’re always trying to be ahead of what the next emergency is.”
As Ware and her colleagues went through the drill last winter, they discussed a scenario involving a respiratory virus. How would they respond if an infected patient arrived on campus? What if 20 patients showed up at once? Would isolation be possible? Did the hospital have adequate supplies of personal protective equipment?
Less than two months later, on March 12, Togus was forced to deal with the real thing after a U.S. Navy reservist from Androscoggin County became the first person in Maine to test positive for COVID-19.
The Togus response, however, had begun three days earlier by limiting access to campus. Soon after, all elective procedures at the hospital were postponed. Within a week, the Maine Center for Disease Control and Prevention reported another 51 cases of COVID-19.
Also within a week, the National Guard erected a large tent to screen patients for symptoms such as fever, cough or shortness of breath before they ever entered a building at Togus. Two smaller tents were used for storage; planning for all three emerged from the drill in January.
“It’s us talking out loud, sharing ideas, sharing what the current situation is, brainstorming,” Ware said. “It’s a good, safe environment to learn. You look at your organization and say where are the risks, where are the vulnerabilities, what do we have to tighten up on?”
The triage tent remained in place until the end of September, when it was replaced with a mobile unit called C-FORTS (Fold-Out Rigid Temporary Shelter) small enough to be towed by a pickup truck and often used in disaster-relief efforts. Many of the staffers still working entry-point control screening were recruited from non-medical areas such as finance and human resources.
As of Oct. 9, a total 49 veterans in the VA Maine Healthcare System had tested positive for COVID-19. Thirty-nine had recovered, and six were being treated as outpatients. Four veterans died from complications related to COVID-19, including one on the Togus campus April 2. The other three infected veterans died at community hospitals on June 3, July 30 and Sept. 30.
Through September, four VA Maine Healthcare employees had tested positive, with two recovered and two quarantining at home. In early October, three more staffers tested positive and underwent outpatient treatment and quarantine protocol.
Over the first seven months since the virus was detected in Maine, no known transmission had taken place on the Togus campus. Thorough planning and quick execution helped prevent any surge, and the hospital entered the fall without having to deal with more than two positive cases in any one day.
That good fortune allowed Togus employees to help elsewhere in the VA system, with volunteers completing a total of 67 two-week deployments around the country, from Maine to Arizona. They brought back knowledge and experience about caring for coronavirus patients and shared expertise of their own, such as when a housekeeping aide from Chelsea, Matt Hamel, introduced a backpack electrostatic sprayer to a New York City hospital for use in sanitizing large items such as waiting room chairs.
Hamel now works as a whole health partner at Togus.
“Looking back, the two really smart decisions we made were to aggressively limit elective care in the beginning of March – we did that ahead of some other hospitals – and second, we really locked down access to campus,” said Ryan Lilly, who spent six years as medical director of VA Maine before being promoted to network director of the larger VA New England system. “Screening at the doors, asking key questions that are pretty commonplace now, that helped us early to stay ahead of it.”
An exception to the no-visitor rule allowed veterans, many of them advanced in age and dealing with chronic health conditions that limit their mobility, to bring a spouse or caregiver with them to health care appointments.
David Patch, 77, a Navy veteran who lives in Boothbay Harbor, said having his wife accompany him on medical visits to Togus has been particularly helpful.
“It’s another set of ears,” Patch said. “You’re elderly and you really need to have that emotional support. I think that has as much to do with mental health as with physical health.”
The only other exception to the visitation policy was for family to be with patients of the Togus nursing home who were in the final stages of life.
“That was very important to us,” Ware said. “They had to wear masks, but we never stopped that.”
Starting April 6, mask-wearing became universal for every one of the 1,100 to 1,300 people on the Togus campus each day. Even those showing up with their own face covering are required to switch to a surgical mask issued upon entrance to the facility.
Cloth face coverings simply introduced too much risk, said Ware, who expressed gratitude for supplies of personal protective equipment robust enough that Togus was able to ship surplus surgical masks to a sister VA facility in Massachusetts where the need was greater.
Togus planners also outfitted a 36-foot bus-like ambulance called a Dual Use Vehicle to transport critically-ill patients to or from other medical facilities within the state or New England. They recruited several employees to serve as patients on a test run to the West Roxbury VA medical center in Massachusetts.
“It remains ready to go if needed,” said Tracye B. Davis, who took over from Lilly as Togus medical director early last year. “Hopefully, we will not need it.”
As restrictions on face-to-face visits on campus mounted, physicians increasingly relied on telehealth services to care for veterans. The VA has its own technology and providers who had been trained on it prior to the pandemic.
Since March, Togus VA has distributed roughly 500 iPads to veterans who didn’t otherwise have access. The number of veterans using telehealth services soared from 575 in February to 5,066 in September.
“It became very clear, very quickly that if we were going to continue to provide quality care and safe care that this was the route we were going to have to take,” said Michele O’Connor, coordinator of telehealth services, who said that more than one in five of the veterans receiving care in the VA Maine system (more than 40,000 annually) have done so virtually.
“A lot of the veterans have really embraced it, and they are actually asking for it now,” O’Connor said. “I think it’s really going to be part of our everyday practice now.”
Indeed, because of lessons learned during the pandemic, designers of Portland’s new VA outpatient clinic under construction on West Commercial Street have carved out space purely for telehealth use. In current practice, examination rooms allow for both in-person and telehealth visits.
Tyler Watson, a strategic planner for Togus and project manager on the Portland outpatient clinic, said other pandemic-related tweaks include information desks that can double as screening locations and larger waiting areas that allow for appropriate social distancing.
Another focus is the capability for “negative-pressure” or isolation rooms that prevent cross-contamination. Prior to the pandemic, the Togus medical center operated two negative-pressure rooms. Thanks to an upgrade a decade earlier, however, the flip of a switch can convert two inpatient wings as well as the intensive care unit into a series of negative-pressure rooms that, in a surge, could create 51 isolation chambers among a total of 156 beds, more than twice the normal capacity of 67.
Ware and Watson were part of the team making that upgrade decision 10 years ago.
“We were hoping we would never see this type of event,” Ware said of the current pandemic, “but it was wonderful that we had that foresight way back when.”
Nobody can predict when the next tornado, blizzard, hurricane or, yes, pandemic will force its way onto the scene. Planning for its arrival? That’s a different story.
“We want to be sure that if we have something like this in the future,” Lilly said, “we’ll be ready there, too.”