Fighting COVID-19 on the Front Lines

3 VA employees explain their roles in limiting the pandemic’s effects

By Everett A. Chasen

When the COVID-19 pandemic hit its first peak in New York City in 2020, Joan Whelan-Schwartz, FNP-BC (family nurse practitioner-board certified) was the national coordinator of a research study called VA-INTREPID, looking at ways to prevent amputations in veterans with diabetes.

To help meet the surge in patients, Whelan-Schwartz volunteered to work in a specially outfitted van parked in front of the James J. Peters VA Medical Center in the Bronx. There, she participated in what the hospital calls “hot triage,” serving as the first point of contact for veterans who came to the facility in need of medical care, reducing the load on the hospital’s emergency department.

Veterans with significant COVID-19 symptoms were sent to emergency, while others were treated in the van and discharged. VA employees who tested positive for the virus were screened in the facility’s triage room, in partnership with the hospital’s occupational health nurse practitioner, before being allowed to return to work.

“After more than 30 years of not working in an emergency room, I had to relearn how to triage patients quickly,” she says. “But it’s like riding a bike. It comes back to you.”

Early in 2020, the federal government committed itself to a whole-of-government response to the pandemic. Coordinating the response is the Federal Emergency Management Agency (FEMA), part of the Department of Homeland Security. Many federal agencies are involved in the fight alongside FEMA.

“We love our veterans and are so happy we can help serve them.”

— Joan Whelan-Schwartz, FNP-BC

For example, researchers at the Centers for Disease Control (CDC) study the virus worldwide and help communities respond to outbreaks locally. The Department of Labor helps employers and workers keep their workplaces as safe as possible and provides advice and updates on special unemployment benefits passed by Congress.

The Food and Drug Administration (FDA) works with the health care industry to develop vaccines, drugs and diagnostic tests. The Department of Health and Human Services (HHS) researches treatments for those who have contracted the illnesses and leads the race to develop, approve and distribute vaccines.

Three agencies provide direct, hands-on health care for Americans: the Indian Health Service; the Department of Defense’s Military Health System; and the Department of Veterans Affairs (VA), which operates the nation’s largest integrated health care system, with 172 hospitals and nearly 1,300 outpatient clinics.

As of December 2020, the VA has admitted 121,765 veterans and employees with COVID19 to its hospitals; 5,229 have died. To get a sense of what the front lines of this battle look like, NARFE spoke with three VA employees: a registered nurse, a hospital administrator and a senior medical researcher.

The Nurse

Whelan-Schwartz, the nurse described at the opening of this article, staffed her hospital’s hot triage area for about six weeks. “We were able to work with other nurse practitioners in the hospital and bring them in when we needed more help. The greatest thing is that all the nurse practitioners who worked in the van remained healthy and free of COVID. Two of my colleagues, John Knapp and Beryl Sinclair, were in that van five days a week for months, and they are still helping screen VA employees and veterans for COVID.”

Today, Whelan-Schwartz is part of VA’s support for Operation Warp Speed, a nationwide project administered by HHS with the goal of producing and delivering millions of doses of safe and effective vaccines to the American people and the world. Her medical center is one of 10 VA facilities and other hospitals worldwide testing the Janssen vaccine in the ENSEMBLE study. This vaccine was developed by a division of Johnson & Johnson.

Neither she nor the volunteers who receive a vaccination know whether they are getting the vaccine or a placebo. If the Janssen vaccine is successful, those who receive it may need only one vaccination instead of the two shots that some other vaccines require.

“We love our veterans and are so happy we can help serve them,” she says.

“By sending staff and equipment from upstate facilities to downstate, we never ran out of equipment ... and we never ran short of staff.”

— Dr. Joan McInerney

The Administrator

Dr. Joan McInerney came to grips with the COVID19 outbreak earlier than most of the general public. Network director of VA Health Care Network New York/New Jersey, McInerney leads nearly 18,000 employees who deliver health care to 467,000 veterans every year. In February 2020, she set up an Incident Command Center to track the virus and plan for what she and her staff would do if it reached the United States.

“Every morning, I heard from VA’s emergency management team [about] what was going on in the world,” she recalls. “I’d bring that up in our Incident Command meetings, and we worked on a potential model for what might happen.

“We started thinking New York City was going to be a hot spot for infections. Our initial plan was to make our Brooklyn hospital the place where we would transfer all our COVID patients, but that didn’t work out. So, all our hospitals [the network operates nine, including inpatient facilities in Manhattan, the Bronx, Long Island, Westchester County and Northern New Jersey] were involved.

“Our work was complicated by the number of patients who needed intensive care unit (ICU) beds and those who needed to be on ventilators. We had to scramble to make sure we had enough equipment and staff. But by sending staff and equipment from upstate facilities to downstate, we never ran out of equipment, including PPE [personal protective equipment], and we never ran short of staff.”

The network created 42 new ICU beds and 148 medically staffed beds. Within weeks, McInerney and her staff hired 425 new employees. The hospitals transformed patient rooms into negative pressure rooms in which the air pressure inside is lower than that outside, keeping potentially contaminated air or viruses from flowing into noncontaminated areas.

They repurposed post-anesthesia care units and reactivated old ICUs, emergency department areas and procedure suites. Trained hospital personnel from upstate New York were sent downstate where their services were more needed, and eventually some were sent to VA facilities elsewhere in the nation.

When other hospitals in the New York metropolitan area were overwhelmed, the network took in 143 COVID-19 cases from the community under VA’s humanitarian support mission. And they provided staff, supplies and training to three New Jersey state veterans’ homes when many of the homes’ staff members and patients became ill.

“Every morning,” McInerney explains, “VHA (Veterans Health Administration) had an operations center call. We all had to present what we were seeing, and by letting

others around the country know what was going on here, we helped them prepare.”

She recalls learning that at a New York City hospital not affiliated with VA, the intense use of oxygen associated with COVID-19 caused catastrophic failure of an oxygen gas system because the pipes were cold. By the end of the day, every VA facility nationwide was aware of the problem.

To protect staff, she allowed those who could do so to work from home and do virtual visits with patients whenever possible. To protect veterans who needed hospital services but did not have the coronavirus, the network greatly increased the amount of telemedicine services it provided, offered curbside service, and conducted home visits so patients did not have to risk exposure in hospitals.

In terms of lessons learned, McInerney mentions the need for transition beds for patients who are recovering but may still be contagious. “We have patients who can’t go home because they have an elderly spouse or are living in a nursing home or are still testing positive even though they are much better. It took us a while to develop a good plan for that.”

She concludes that communicating with fellow employees “is the biggest thing. Keeping the staff healthy and unexposed is really important—because otherwise you’re not going to have the staff.”

The Researcher

Dr. David Atkins directs VA’s Health Service Research and Development Service, overseeing more than 300 projects aimed at improving the health of and care for our nation’s veterans. He also heads VA’s COVID Observational Research Collaboratory, bringing VA experts together to analyze the use and effects of COVID-19 therapies with clinical partners interested in the safety and effectiveness of those therapies.

“At the beginning of the pandemic,” he says, “we didn’t have any effective treatments. Clinicians were trying everything. We started the Collaboratory to learn what treatments doctors were using and to see whether there were any signs that some of those treatments were effective.”

Because VA has a comprehensive electronic health records system that can be mined for data, the department is a good place to examine the value of different treatments. “We started out by working with FDA and then decided we should have an organized process to determine which questions were especially relevant to VA and make sure our researchers were using the best available science,” Atkins explains.

“Studying COVID-19 is a complicated picture, and it’s easy to get a wrong answer if you don’t know what you’re doing. The Collaboratory is a way to ensure the science will be better than if we just let everyone do their own thing. Otherwise, we might have five different VA studies with five different conclusions.”

The Collaboratory began by funding three teams to look at important questions related to COVID-19 therapies. These included the value of anticoagulants in treating the illness; the effectiveness of remdesivir, an antiviral medication; and the helpfulness of steroids like dexamethasone, now the standard for treating patients with severe and critical COVID-19.

Another Collaboratory work group looks at ways to improve the underlying data and methods VA is using to address these questions.

“VA can look at the pandemic across multiple settings and populations. We can follow it over time and see how the situation has changed. And we can take the things we’re learning and spread them quickly throughout our health care system.”

— Dr. David Atkins “They review the methods of different studies, provide advice and comments, and make sure investigators understand the intricacies of VA’s data set and the ways different things are recorded in VA’s electronic health record,” says Atkins.

Recently, the Collaboratory began looking at the long-term outcomes of patients who have had COVID-19. “Some patients recover but don’t get completely better and have symptoms that can last a long time. There’s a lot of interest in this, but we don’t really know that much about it yet.”

Now that vaccines to protect against COVID19 are being distributed, the Collaboratory researchers are looking at veterans’ attitudes toward taking the vaccine and at the best way to administer vaccines to VA’s 9 million health care enrollees—how appointments will be handled and how to ensure patients who have received the first dose of the vaccine return for their second dose, if needed.

Atkins notes the special value VA research offers in the fight against COVID-19. “VA can look at the pandemic across multiple settings and populations. We can follow it over time and see how the situation has changed. And we can take the things we’re learning and spread them quickly throughout our health care system. VA is really going to be helpful in determining whether we are seeing side effects from vaccines once we start giving them to hundreds of thousands of people.”

“We have a population with a lot of vulnerable patients,” he says. “So far, we’ve been relatively fortunate that the toll on veterans has not been as high as one might have expected— but we are finding some of the same patterns as in the general population, that African Americans and Latinos are more likely to get the disease than white veterans. The good news is that we’ve seen no disparity of outcomes among infected patients, so VA is living up to its promise to treat everyone equally.”

—EVERETT A. (EV) CHASEN IS A WRITER AND COMMUNICATIONS CONSULTANT IN THE WASHINGTON, DC, AREA. HE IS RETIRED FROM THE FEDERAL GOVERNMENT AFTER 35 YEARS OF SERVICE.