The Daily Dose • Friday, May 14, 2021
Critical Care Services Reimagined after COVID-19
Four clinicians with experience on the frontlines shared how institutions adapted and grew to meet the unimaginable needs faced during the early months of the COVID-19 pandemic in “Education Session IV: A Look Back at the Surge: What We Found Ourselves Doing That We Never Anticipated” on May 14 during the SOCCA 2021 Annual Meeting.
Palliative Care on the Front Lines of the Surge
After living the experience of caring for COVID-19 patients in the ICU throughout the pandemic, Rebecca Aslakson, MD, PhD, FAAHPM, FCCM, Division Chief of Critical Care Anesthesia, Division of Anesthesiology, Pain and Perioperative Medicine at The Stanford University Medical Center, looked at the COVID-19 mortality data through November 2020 to determine what the data tells us. Mortality data varied widely across institutions, but COVID-19 was associated with high mortality and very poor outcomes following in-hospital cardiac arrest and for patients requiring invasive procedures. CPR was ineffective for many of these patients.
In a study from Sweden, entitled “Were Clinical Routines for Good End-of-Life Care Maintained in Hospitals and Nursing Homes During the First Three Months of the Outbreak of COVID-19?” by Martinsson, et. al., all COVID-19 deaths were compared to all deaths in 2019 as well as to all non-COVID deaths in 2020. The results showed that COVID-19 patients who died in 2020 received significantly poorer quality of care in the last week of life than patients who died of other causes.
In a study from University of Pittsburgh, researchers examined effectiveness of various communication approaches for patients in the ICU. Tips from their investigation included identifying a family point-person to receive updates, frequently checking family understanding, positioning the camera for video calls so family can see the patient and their care setting and offering time for family to interact without healthcare workers present.
Despite the struggles, many hospitals developed diverse approaches to managing end-of-life care for COVID-19 patients. Dr. Aslakson highlighted Mount Sinai Health System in New York City for its impressive palliative care initiative during the pandemic. They provided additional COVID-19 comfort care units, palliative care physicians, nurses, and social workers, and telehealth to support the COVID-19 response from the ER to the ICU settings.
Stretching the ICU Spaces, Equipment, and Personnel to Accommodate an Unprecedented Patient Volume
In March of 2020, Columbia University Medical Center responded to the COVID-19 surge in NYC by expanding ICU bed capacity from 117 to 287 beds. Vivek Moitra, MD, Division Chief, Critical Care Medicine; Medical Director, Surgical Intensive Care Unit; and Medical Director, Cardiothoracic Intensive Care Unit at Columbia University Medical Center, shared the strategies used to maintain standard-of-care while managing an influx of critically ill patients during these difficult times.
ICU bed capacity was increased by repurposing OR rooms, reimagining staff roles, and adapting anesthesia machines to create 82 additional ICU beds in a unit called the operating room intensive care unit. OR suites were modified to create negative pressure suites. Multiple ventilated patients were housed in each OR suite. Anesthesia ventilators were modified for ICU care by removing vaporizers and HME filters were used to decrease anesthesia machine contamination.
Staffing was augmented by allowing senior residents and fellows to take on new responsibilities with additional training and supervision. Noncritical care specialists received training to manage COVID-19 patients. Dr. Moitra emphasized the significance of the support and gratitude from the citizens of New York City that boosted the morale during this response.
ECHMO for the Epidemic-the Good, the Bad, the Lessons
Michael Nurok, MBChB, PhD, FCCM, Medical Director, Cardiac Surgery Intensive Care Unit at Cedars-Sinai Medical Center, explains the struggles faced when determining which critically-ill COVID-19 patient would receive ECMO during the pandemic. Prognostic uncertainty involves asking who will benefit from intensive care resources. Studies indicate that clinicians predicted very poorly which COVID-19 patients would benefit from these resources.
Dr. Nurok referenced several ethicists for examples of how to best make these decisions regarding care. Ethicist Immanuel Kant proposed decisions made by our obligations or duties. If care is needed, we should provide it regardless of resources. Utilitarian ethicist, Jeremy Bentham, proposed the theory of maximizing well-being. In other words, decisions are made based on the greater good of the entire population, not the individual. Prepandemic and pandemic allocation of intensive care resources shifted from considering profit and maximum support for the individual to considering availability of limited resources for the entire population.
The proponents of ECMO use during the COVID-19 pandemic believed it provided better lung protection during ARDS and availability of circuits. Reasons against using ECMO were the need for increased staffing, space, and PPE to care for these patients. As COVID-19 cases increased, access to ECMO was restricted due to decreased availability of resources. Clinicians were placed in an uncomfortable position, determining who would benefit from these limited resources.
The Importance of Networking during a Global Pandemic
Early on, when the novel coronavirus was making headlines in China and Italy, clinicians searched for information on clinical presentation, patient management, and how to best prepare our medical infrastructure for this growing pandemic. Allison Dalton, MD, Associate Professor SOM of Anesthesia and Critical Care at The University of Chicago, delved into some of these findings during her presentation.
Networking opportunities provided information and idea sharing between clinicians from around the world that was critical in early preparation for COVID-19. In early 2020, networking provided information via personal contacts and email groups. By March, professional websites, organizations, online communities and social media were used to disseminate information. Several months later online training for nonintensivists, correspondence articles, and prepublication articles became available.
Networking during the pandemic taught us how continuous information sharing and networking within professional societies and the availability of free online resources during times of crisis can provide invaluable resources.