Leadership on the frontlines

Welcome to Effective Nursing in Times of Crisis, from Johns Hopkins University.

In this interview Dr. Jason Farley discusses his role in leading responses to the
COVID-19 pandemic and provides important lessons from the frontline on the
importance of nurses providing the patient’s voice.

Patricia Davidson:
It's my great pleasure to have a conversation now with one of my colleagues, Dr.
Jason Farley. Jason Farley is a professor in the School of Nursing. He leads our
Reach initiative, and he is a global leader in HIV and tuberculosis care.

With these strong foundations in the management of infectious diseases. He's found
himself at the frontline of managing the COVID-19 pandemic, not just here at the
Johns Hopkins School of Nursing, but being a voice for nurses all around the world.
So thank you so much, Dr. Farley for joining us here today, and I’m interested in
hearing about your views of leadership in a time of crisis and what are some of the
lessons that you've learned being thrust into this environment?

Jason Farley:
I think that first and foremost, that nurses inherently are our leaders in many different
ways. Whether it's at the command centre level of Johns Hopkins Hospital, I see
nurses engaged at all levels, everything from material and supply management and
stock, and how we clean the stock that's been in COVID rooms, to up to the highest
levels of hospital epidemiology and infection control, protecting frontline healthcare
workers through PPE. I have also seen a variety of nursing voices across the United
States and around the world, lending their expertise to the epidemic and not only
educating the public, but educating the scientific community as well about the role of
both nursing in an epidemic, or in a pandemic as the case may be, and how it is
influencing everything from political decision making, to the way we think about the
way education is delivered, to the way we think about general infection control and
the public and how they practice appropriate infection control as they go about their
daily lives while navigating a pandemic.

Patricia
Doctor Farley, you briefed Congress at the beginning of this pandemic? What was it
like being there? And what were some of the strategies you use to provide a nursing
voice in those complex conversations?

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Jason:
Well, when you get a room of experts, no matter who your audience is, whether it's
Congress or it is your patient in the hospital, when you get a group of experts,
whether it's the rounding team at the bedside or group of colleagues in front of
staffers on the Hill, you can easily go into jargon and and scientific speak, that often
loses the message. So I think first and foremost, as we all know as nurses, at the
bedside, a rounding team of clinicians may often present the patient with a glorious
summary of their progress or prognosis, and then leave the room leaving the patient
alone with the nurse to then translate everything that was just said in a way that
patient can understand it. So I think first and foremost, a role on the Hill is to make
sure that the people in the room actually understand the message and receive the
message accordingly. So ensuring effective communication is an extremely important
role.

But then also helping people to understand that nurses are more than frontline care
providers. That is one of the most important things we do. There are also other
parallel roles that we play including the scientific role, thinking about how the virus
transmits, thinking about how we are engaged in a variety of clinical duties and roles,
and how the quality of that clinical duty and role can be maintained. For example, I
was just on a wonderful call with some infectious disease clinicians talking about the
data related to proning patients with COVID-19. So simply by rolling them on to their
stomach. And so as they went through all of the science of exactly what's happening
from a gravity perspective, what's happening at the alveolar level, what's happening
at the tissue level when you're proning a patient, and then the response occurs as a
result of the oxygen saturation. I kept sitting there thinking, not once has anyone
mentioned the patient's comfort related to proning. And every single time when I have
been on a COVID unit and the oxygen saturation falls, and the nurse says to the
patient, ‘Okay, we need you to roll on their stomach’, there is an audible groan.
Patients don't like it. They're uncomfortable and we know it's best for them, right? It's
good for them. So the nurses left to coach the patient about the importance every
time, about how to like, ‘I know this isn't the most comfortable position for you, but we
really need to do it’, and then actually show them their pulse oximetry to show them
how it improves just by proning them. So we talk scientifically a lot about these
different, you know, easy to understand as a scientist metrics. But then human
behaviour is so much more complex, and it's often the nurse who is translating the
science to the actual implementation, and, operationalization of that at the bedside.
And I think it really requires great communication skills, whether it's at the halls of
Congress or at the bedside with the patient.

Patricia:
Excellent comments. So Dr. Farley, you've had such a strong foundation in infectious
diseases and you know, you care for people with HIV, here in Baltimore and South
Africa and many other parts of the world. Have you drawn any

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similarities from, or skills from caring for patients with active tuberculosis or untreated
HIV in terms of managing this pandemic?

Jason:
I think first and foremost, if you look at the leaders who the administration have called
upon to lead this response, all three of them. Dr. Fauci, Dr. Birx and Dr. Redfield are
HIV clinicians. They have gotten their start and they've built their scientific portfolios
in the space of HIV. I think, for us in the HIV world, there are many parallels in this
epidemic. I think, first and foremost, we've seen a lot of stigma that has arisen, just
like in the early days of HIV, and that is stigma not only at the community level, where
patients in the United States for example, initially we we thought the virus arose from
China, we now have emerging data that that is not necessarily the case. But
individuals of Asian descent in the United States were experiencing direct racism and
discrimination, very similar to gay men and IV drug users and people from Haiti early
in the HIV epidemic in the United States. Continuing that thinking forward, we've also
seen healthcare workers who had an exceptionally large amount of fear as data was
rolling out. And in the early days of the HIV epidemic, we had healthcare workers flat
out refuse to care for patients with HIV, back when we had little understanding of how
the disease was transmitted. Today with COVID-19, most healthcare workers have
stood up and stood out in their volunteerism and willingness to work with COVID-19,
and yet, still, we do see a fairly large amount of fear associated with transmission.
Unlike HIV, healthcare workers are saying ‘Yes, I will do this, but I want to be
protected with the absolute most beneficial level of PPE possible’, which is a great
consideration. But we do know in the effects control space, that not all risk for
healthcare workers is the same. So if you're intubating, a patient or nebulizing, a
patient, we're doing procedures in the airway of a patient including ear, nose and
throat surgeries and neurological procedures that are in the upper airway, those are
the highest risk for infection of the healthcare worker. And so we've been working
directly with our engineering colleagues, both in Johns Hopkins School of Nursing,
the Whiting School of Engineering at Johns Hopkins and others, to think about how
you might develop a hood that might go over the head of the patient and still allow
the clinician to work effectively within the airway and also limit transmission. Yet, if for
example, if I'm in the space of a unit with COVID patients, I myself, for example,
would be in an N95 and not necessarily need eye protection if I'm simply on a unit
and the patient is in a room with a closed door and negative pressure. So we know
that not all risk is the same. We know that this is a aerosolisable virus and not an
airborne virus. And I think that's a critical distinction. So I -through the technique and
the thing that I do to the patient can cause the virus to go into the air and be aloft on
air currents. If that is not happening to the patient, it's very unlikely that the patient
aerosolizes the virus and causes infection down the hallway. Unlike measles, that
we've seen hotel level transmission of that virus, for example. So I think you know,
one of the things it's really important for people to understand is that we know a lot
now about how this virus transmits. We know a lot about how

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people can be transmitting the virus when they're asymptomatic, and we know a lot
about the ways we can protect the health workforce.

So, however, we learned all of that in the matter of weeks. If we think about HIV, the
first known cases, we now know the first known cases of HIV occurred in the 1950s.
But when we identified the virus in the US in 1981, we didn't develop tests for this
virus until 1985. So four entire years. And we're complaining right now about four
weeks, right, you know, between when we identified the virus and really began initial
testing, and we're still complaining, you know, now eight and possibly moving into 12
weeks about not enough testing, but in parallel, we know what the virus is, we know
how to do a PCR to obtain that virus. We also know how to test for antibody to that
virus. And so I think, you know, the speed in which we've responded to coronavirus is
remarkably different than the speed in which we responded to the HIV epidemic.

Patricia:
So a lot of your role has been, particularly in the States, is helping people understand
these infection control procedures. And I guess many of us sort of in nursing school
learn about donning and doffing and you've been giving people rapid refreshers. For
people that are on this course, what are some of the key messages that you would
give to them to be able to refine their donning and doffing techniques as well as how
they would communicate to their colleagues?

Jason:
First and foremost is to establish and follow a routine when both donning and doffing
your PPE. So obviously when donning the PPE, it's about making sure you've got the
fullest level of protection, and they are easy to follow. For example, what we've done
at our Baltimore City convention centre or at Johns Hopkins is to establish safety
officers, so people who were there specifically to help watch you put on and watch
you take off your PPE to protect you. So first and foremost is utilise this person, as if
they are your lifeline. I'm a diver and every time I go diving, I have a dive buddy who's
responsible for my safety as I am responsible for their safety. And it's the same
principle if -you would never jump into water and be 100 feet under the water without
someone fully checking to make sure everything was in working order. Same - you
should never go into a Coronavirus unit or to an area that might have people under
investigation without someone fully checking to ensure that you have met the
appropriate safety precautions. So routine and a safety officer or safety buddy, and
then doffing the PPE, so taking the PPE off is really essential. Because now you
consider everything that you're wearing, including, your gown and your gloves and
potentially your mask, depending on face shield, covered or not, is potentially
contaminated with virus, right. And so where we believe most healthcare workers
have the greatest risk of exposure is by touching their PPE and getting that onto their
hands or onto their clothing and then subsequently touching their mucous
membranes. And so having that safety officer again, follow a similar routine when
taking off the PPE is essential, even more so

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than putting on the clean PPE, right. And so, but I have to admit, having done this,
you know, for a full 12 hours on a COVID unit, you know, going in and out of patients
rooms, it is exceptionally labour intensive. So, there are times in which, you know, in
a room where the patient was cold and had their heat turned up that I am a bucket of
water in that circumstance. And that's just the circumstance you're under. So going in
and out of those rooms repeatedly adds a lot of fatigue to set in. And so you must
make sure you maintain the same level of precision the first patient of the day as you
do on the last patient at the last time you exit a room at the last patient in the
evening. It's really critical.

Patricia:
So today Dr Farley, there's a lot of excitement about the first release of the
Remdesivir results. And people may be thinking that we're getting closer to the end.
But the epidemiologists tell us that's not the message. And for nurses around the
world who are doing this course and are learning how to follow the data and learn
important lessons in how they manage their practice, what would be some of the key
messages you would give to them?

Jason:
Yeah, I think first and foremost is ensure that you understand your own facts, and
that you've sourced your own information. I feel that right now there is just as much a
pandemic of the virus as there is a pandemic of misinformation about the virus and
the spin that is going on around the world from the news media and countries and
ministers of health and others is extremely important to cut through. So let's
understand what we know about the immunology of the virus. First and foremost, if
we think about the common cold and Coronavirus, we know that with the standard
common cold level Coronavirus, and there are four of those types of Coronavirus,
that immunity is likely to last 12 to 24 months after infection, but that's different for
each individual. So we know that lifelong immunity is typically not guaranteed. We
know that with SARS and MERS, more pathogenic versions of Coronavirus, more
similar to COVID-19, that the sicker the patient was who recovered, the more likely
they were to get broadly neutralising antibodies. And yet still, they did not develop
lifelong immunity in those infections. Third, we currently have no vaccine. So,
importantly, as the virus has gotten such a large level of global penetration, we
expect the virus to become endemic, meaning that it will move from a pandemic form,
right, new and infectious, to routinely circulating in the human population. So when
we think about where we're going with this vaccination campaign and where we're
moving, you know, we're talking about global level immunisation for COVID-19, when
that is available. And there's some hope on the horizon that that might be available in
a shorter timeline than the 18 months originally projected. We're hopeful that initial
data might be available as soon as this fall, which is great.

But moving on to the therapeutic, the Remdesivir, from Gilead Sciences. So the drug
has now been trialled and we have seen data from two studies published this week,
or reported by the NIH this week, I shouldn't say published, because these

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are preliminary data analyses by the data safety monitoring board. And basically,
that's the safety monitoring board that's independent from the investigators doing the
trial, who will analyse the data and say basically, whether or not they feel that there's
a signal that they are identifying. And so the first study actually identified was whether
or not a five day dosing or Remdesivir was effective versus a 10 day, and they found
pretty much the five day was equivalent to the 10 day suggesting that we could,
importantly, increase the amount of drug available by reducing the overall duration of
therapy. So that's the first thing. So that's a supply chain issue.

More importantly, though, was the randomised control trial conducted in multiple
countries around the world with over 1000 patients that compared Remdesivir to
placebo. And in that study, there were two important initial findings. The first was that
it shortened by about 30% the duration of illness defined as discharged from the
hospital or significant improvement in symptomatology. And so what that means was
the people that received the treatment, the Remdesivir, had an overall median time of
symptoms of 11 days, compared to the placebo group which was 15 days. So it
shortened the overall duration by four days.

On mortality, this is the important thing. The mortality in the placebo group was
11.6%. And mortality in the treatment arm was 8%. Now, importantly, the p value, or
the statistical significance, of this finding was not significant. It was .056. So with that
data, it clearly shows that there is a ray of hope, but by no means from a mortality
perspective did the drug show efficacy in comparison to placebo based on mortality
outcome. And I think that's the critical point. Yes, as it was mentioned, all over social
media that as well as in the presidential briefing here in the United States, there is a
ray of hope with this drug, but by no means is that ray of hope a light completely at
the end of the tunnel. It is our first glimpse of preliminary data. It is an analysis that is
ongoing. It is an analysis that clearly needs a larger sample size to hopefully push us
over the statistically significant finding. And I think I am hopeful that we will get good
results. At the same time, the drug does come with a myriad of side effects. It is
classic, if you look in the HIV days, when we first launched AZT. AZT was life saving.
It took years to get that drug approved. So quite a different response with COVID-19
than with the original drug with AZT. But it did save lives. We saw quickly that the
virus mutated and became resistant to AZT and the drug stopped working, and the
toxicity profile of AZT is such that we would never use that medication today. And so I
think while we have, again, that ray of hope, it is not a light at the end of the tunnel at
this point, because toxicity needs to be continually evaluated. It did not reach
statistical significance in terms of mortality outcome. It shortened time to symptom
resolution by four days. And so I think these are all important things to consider when
truly evaluating the drug. I think what will happen is because we have nothing else at
this point, the FDA will approve the medication based on these preliminary findings. I
think it will move swiftly into production. And I think we will ultimately see its real
world impact when it gets into the hands of prescribers who can use the drug more
broadly.

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Patricia:
So Dr. Farley, a real focus of your work has been a holistic focus on the patient and
also, it's not your single organ, single disease focus. So as you mentioned COVID-19
is going to be endemic and in many parts of the world you work with people who are
most vulnerable who are exposed to tuberculosis and HIV. How do you think
COVID-19 is going to add into how you take care of those populations, and how you
move the field forward to maybe now looking at this era of multi-morbidity and
multiple sources of illness?

Jason:
Sure. You know, well, the one piece of really great data that seems to be consistent
right now across the world is, and this could change tomorrow, but what we're seeing
right now is that patients with HIV seem to not be in the highest risk group, in terms of
diabetes and cardiovascular disease and other respiratory illnesses. Surprisingly, so
far, we've not seen a marker that HIV is a risk factor for severe illness. People with
HIV, particularly those with a higher CD4 count and or a viral suppression are at no
greater risk than the general population. If that person, however, has cardiovascular
disease, or respiratory disease or diabetes, then that puts them in the same category
of risk.

In relation to tuberculosis, another respiratory illness, certainly there's cause for

extreme concern. We've seen any respiratory illness like asthma or anything that
impacts the ability of oxygen, you know, exchange, including tuberculosis, particularly
severe forms of tuberculosis, you can get individuals who have difficulty with their
actual clinical presentation. So, right now, I think the most impactful ways that we are
seeing this begin to occur is we've seen TB hospitals converted to COVID-19
hospitals. So patients are losing some bed capacity for tuberculosis. We've seen
around the world patients, HIV clinics need to move those patients on to telemedicine
or telephone visits. I just had a lovely patient visit yesterday who cannot do
telemedicine because he doesn't have internet at home and does not have a
smartphone, and has extreme challenges reading. So we did a telephone visit as
opposed to a telemedicine visit, and so that that helps us set up the framing that is
there a potential for disparity that could be forming between the people who have
internet access, who have the ability to see someone on camera like this and have a
connection, as well as to really engage with someone in a personal level, right,
bringing the patients into your home, bringing you into the patient's home for
telemedicine it's definitely an intimate experience. I've gotten to meet up front some
of those dogs that I've heard, and I've gotten to meet up front some of the family
members that I've heard talked about for years in my patients with HIV here in
Baltimore. But I'm also struggling with making sure that our patients have equitable
and equal access to their care. So, our pharmacy, for example, has transitioned all
patients to have options of being able to send their medication directly through mail to
their home. We've offered all of our patients, whether it's for prevention for
Pre-exposure prophylaxis (or PrEP), or their HIV treatment, to move into a
telemedicine appointment. Telemedicine is something that my team at the Reach

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Initiative has been doing for over two years now for our patients with HIV prevention
needs. And patients love that approach. And so really thinking about how we engage
with our community in the best possible way. And also give them that holistic
wraparound services for adherence and substance abuse treatment and mental
health services, as well as the prescribing aspects that we as providers do are really
important.

Patricia:
Well, thanks so much, Dr. Farley. Firstly, thank you for all you've been doing. I know
you've been very busy. Thank you for your leadership. Thank you for your advocacy
for patients and for nurses, and we wish you all the very best for this pandemic. So
thank you.

Jason:
Be well, everyone.

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