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STOP-VIRUS ICU Learning Collaborative

Join a network of intensive care units focused on improving outcomes for patients with COVID-19.

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The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 (STOP-VIRUS) Learning Collaborative is a network of intensive care units (ICUs) focused on improving outcomes for patients with COVID-19. This six-month learning collaborative fosters a multisite learning system of U.S. hospitals currently participating in the SCCM Discovery VIRUS Registry. The collaborative focuses on identifying and implementing interventions aimed at reducing marked variations in the outcomes of critically ill patients unexplained by demographics, comorbidities, and severity of illness.

This site provides updates and learning materials for best practices from the collaborative. Applications to join the collaborative are now closed.
 

Built on the principles of the Mayo Clinic Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) program, which has proven effective at improving ICU processes and patient outcomes (Marija et al. Crit Care Med. 2021;49:e598-e612), STOP-VIRUS provides participating sites opportunities for active learning, dissemination of successful innovations, resources, and peer support to drive quality improvement and change management in their ICU practice settings.

The STOP-VIRUS Curriculum will focus on the following topics :

  • Approach to Respiratory Failure in the COVID-19 Patient
  • ICU Liberation Bundle (A-F): Implementation and Challenges
  • Infectious Complications and Management of COVID-19
  • Cardiovascular Complications: Venous Thromboembolism, Myocarditis, and Shock
  • Shared Decision-Making and End-of-Life Care
  • Fluids, Electrolytes, and Acute Kidney Injury

During weekly Zoom sessions, STOP-VIRUS subject matter experts will deliver state-of-the-art updates for each curriculum topic area. The updates will comprise a summary of currently understood COVID-19 best practices and an update on current literature. Implementation experts will also help nurture the learning community and offer advice on best practices for local site dissemination and implementation efforts. Participating sites will also have the opportunity to continue the dialogue with subject matter experts and program faculty over Twitter via the hashtag #STOPVIRUScollab. 

This educational activity was funded in part by a cooperative agreement with the Centers for Disease Control and Prevention (grant number 1 NU50CK000566-01-00). The Centers for Disease Control and Prevention is an agency within the Department of Health and Human Services (HHS). Its contents do not necessarily represent the policy of CDC or HHS, and should not be considered an endorsement by the Federal Government.

STOP-VIRUS Collaborative Participating Sites

Learn more about the many hospitals and teams participating in the collaborative throughout the United States .

Faculty

Faculty oversee the development and delivery of the STOP-VIRUS Learning Collaborative educational content and materials.

Moderators

Moderators oversee planning for each curriculum topic block. Moderators interface with presenting sites and subject matter experts, facilitate discussion during weekly video meetings, and continue conversations over Twitter and the Mayo CERTAIN Blackboard platform between meetings. 

Subject Matter Experts

Subject matter experts deliver state-of-the-science and evidence-based updates to learning collaborative sites. Subject matter experts are distinguished experts on the curriculum topics. 

Curriculum Topics

Introduction

While early reports proposed that acute respiratory distress syndrome (ARDS) due to COVID-19 had unique characteristics, growing evidence suggests that a conventional management approach to the management of respiratory failure is most appropriate.

In addition to the severe hypoxemia often occurring in critically ill patients with COVID-19, the high ventilatory drive and minute ventilation often occurring during the inflammatory phase present significant challenges to conventional management strategies. These challenges typically include:
  • Early intubation
  • Low tidal volume ventilation (4 to 8-mL/kg predicted body weight)
  • Higher positive end-expiratory pressure levels
  • Plateau pressure < 30 cm H2O
  • Maintaining driving pressure < 15 cm H2O
  • Consideration of paralysis or prone positioning if these mechanical ventilation goals cannot be achieved
  • Extracorporeal membrane oxygenation (ECMO) support in carefully selected patients

Because of these challenges, many COVID-19 patients with severe hypoxemia have been managed with high-flow nasal cannula oxygen or noninvasive ventilatory support with or without self-proning to avoid the complications associated with heavy sedation and paralysis that are part of an effective lung-protective strategy following intubation.

The best approaches to noninvasive respiratory support, risk of self-induced lung injury, timing of intubation, and subsequent management of refractory hypoxemic respiratory failure remain controversial.
 

Assessment

While noninvasive respiratory support is sufficient for some patients, invasive mechanical ventilation is necessary for many patients with COVID-19 ARDS. Various strategies have been used to optimize the decision and timing of intubation, including the use of formal scoring systems such as the ROX index and the HACOR scale.

Adherence to lung-protective mechanical ventilation and prone positioning remains suboptimal among patients treated with invasive mechanical ventilation. Prone positioning has been demonstrated to be beneficial in nonintubated patients with respiratory failure.
 

Learning Modules

Noninvasive Management of Respiratory Failure during COVID-19: Case Presentation; Nutrition Support for the COVID19 Patient = NIV/HFNC
 

Resources

High-Flow Nasal Cannula Oxygen/Noninvasive Ventilation Awake Prone Positioning Scoring Systems Mechanical Ventilation and Prone Positioning in Adults With ARDS

Introduction

Clinical workload and challenges in care delivery due to shortages of staff, personal protective equipment, and medications during the COVID-19 pandemic have resulted in lower adherence to evidence-based best practices summarized in the ICU Liberation Bundle (A-F). Reduced adherence to the bundle increases several risks, including:
  • Delirium due to prolonged or deep sedation and absence of family visitation
  • Prolonged mechanical ventilation due to variations in spontaneous awakening trials and spontaneous breathing trials
  • Post-intensive care syndrome (PICS)
Several studies suggest that strengthening workflow and care processes to ensure the consistent delivery of bundle elements represents the most important modifiable factors for improving the outcomes of critically ill patients with COVID-19.

Best practices identified by institutions participating in the STOP-VIRUS Collaborative include:
  • Developing multimodal pain and sedation regimens guided by ICU pharmacists
  • Use of videoconference technology and adoption of more liberal visitation policies to increase family engagement in delirium prevention
  • Early engagement of occupational and physical therapy in a structured mobility program
  • Instituting a key role for dedicated clinics to care for ICU COVID-19 survivors and patients with PICS


Assessment/Resources

Get detailed information and implementation resources associated with the ICU Liberation Bundle


Learning Modules

Introduction

COVID-19 clinical manifestations and management have been a major focus of critical care since the COVID-19 pandemic began. The high volume of information published has resulted in significant challenges in synthesis and implementation. Routine use of treatments that have not been systematically evaluated outside of a clinical trial is not recommended.

Management of critically ill patients with COVID-19 includes:
  • Corticosteroids in patients with respiratory symptoms and hypoxemia
    • Significant opportunities remain for further refining both dose and duration of multiple regimens.
  • Remdesivir in patients with hypoxemia and risk factors for clinical deterioration
    • Patients requiring mechanical ventilation or ECMO are less likely to benefit.
  • Tocilizumab or baricitinib in patients with evidence of a significant inflammatory response with rapidly escalating respiratory support requirements

Bacterial coinfection is uncommon early in the COVID-19 course but should be considered in the setting of clinical relapse or delayed deterioration.
 

Assessment

The management of patients with COVID-19 remains a rapidly changing area of investigation. Clinical decisions should be based on up-to-date evidence, including SCCM’s Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19).

The best approach for managing patients with clinical relapse or delayed deterioration, especially in the setting of baseline immune system compromise, remains challenging and controversial.

Checklists have been shown to be effective in decreasing device use rates and should be considered to strengthen ICU workflow processes to combat nosocomial infectious complications.
 

Learning Modules


Resources

Introduction

COVID-19 has been associated with both arterial and venous thrombotic complications, in addition to myocarditis and dysrhythmias. Children with COVID-19 can present with multisystem inflammatory syndrome (MIS-C), which can be life threatening.
  • Meticulous adherence to venous thromboembolism (VTE) prophylaxis is essential to prevent venous thrombotic complications.
    • ICU pharmacists play an essential role in ensuring adequate dosing. Some ICUs have used factor Xa measurements in patients with obesity and renal impairment
  • Therapeutic coagulation for thrombosis prophylaxis is currently not recommended for critically ill patients because it has been associated with increased bleeding risk.
  • MIS-C leads to a combination of distributive and cardiogenic shock. Methylprednisolone and IV immune globulin are commonly used, in addition to hemodynamic support.
 

Assessment

Further research is needed on risk factors and more targeted treatment strategies for the cardiovascular complications of COVID-19.
 

Learning Modules

 

Resources

Anticoagulation in COVID-19
MISC-C

Introduction

The COVID-19 pandemic has created a number of challenges in regard to ethical allocation and patient-centered care. These sessions offer discussion by a wide variety of experts on opportunities for improvement in current triage methods and the importance of patient-centered decision-making to reduce the risk of PICS and minimize healthcare professionals’ moral distress.
  • Restrictive policies on family presence in the ICU have challenged therapeutic relationships and shared decision-making and degraded trust between healthcare teams and patients and families.
  • Although technology solutions help bridge these gaps, systematic communication strategies with dedicated supporting resources are necessary to close current workflow gaps and strengthen shared decision-making practices.
  • There are many opportunities for improvement in critical care triage strategies when resources are limited. Early palliative care engagement should be strongly considered when quality of life is limited and the risk of death is high.
  • Tools such as the Get to Know Me Board can help avoid anonymity for critically ill patients and can humanize their care.


Assessment

The COVID-19 pandemic has underlined the importance of a systematic approach to risk factors and symptoms of burnout among healthcare professionals. An important element of this approach is ongoing efforts to humanize the ICU practice environment and to strengthen relationships between healthcare teams and patients and families to ensure thoughtful, patient-centered decision-making and compassionate end-of-life care.


Learning Modules

Introduction

Acute kidney injury (AKI) is a frequent complication of severe COVID-19. AKI is caused by both direct viral effects and a variety of indirect mechanisms, including intravascular volume management, medication side effects, and the systemic inflammatory response.
  • Appropriate intravascular volume resuscitation, medication dosing, and the avoidance of nephrotoxins when appropriate remain the optimal strategies for minimizing AKI in critically ill patients with COVID-19.
  • Collaborative planning was necessary early in the pandemic to ensure sufficient dialysis resources to meet the clinical demands of both critically ill and chronically ill dialysis patients.
 

Assessment

Evidence suggests a high rate of long-term renal recovery in COVID-19 survivors, even in the setting of AKI requiring renal replacement therapy.

Renal replacement therapy proved to be an important and limited resource early in the COVID-19 pandemic. Future planning efforts for critical care surge capacity should carefully consider both resource and planning contingencies to meet the needs of both acutely ill and chronically ill patients with kidney disease.
 

Learning Modules

 

Resources

Introduction

Translating new knowledge, skills, and attitudes into daily ICU practice can be challenging without a systematic approach to quality improvement and implementation. These sessions offer a rapid review of the define, measure, analyze, improve, and control (DMAIC) approach to quality improvement, with immediate application to a variety of quality improvement projects initiated by various participating members of the STOP-VIRUS Collaborative.
 

Learning Modules

 

Resources

STOP-VIRUS Learning Modules

COVID-19: Lessons from the Frontline
COVID-19 case presentation from the team at Mayo Clinic - Florida that brings together many of the STOP-VIRUS Collaborative lessons learned over the course of the past 6 months.
Supporting Our Community: Well Being, Moral Distress, and Burnout
Erin Strong, BSN, RN, CCRN from the University of Pennsylvania, Amanda Frary, MSN, RN; Sydney O'Brien, RRT and Amber Dewey, RRT from Valleywise Health focus on the bedside experience during the Pandemic.  Karen Korzick, MD from Geisinger Medical Center, discusses how these experiences can lead to moral distress, and place providers at risk for burnout. Closing the discussion, Karen Korzick, MD, Elly Fitzpatrick, DNP, RN, from Thomas Jefferson University, and Greg Martin, MD, from Emory University and current SCCM President, talk about team, unit, and organizational solutions that have been attempted to prevent, combat burnout.

Curriculum Topic: Shared Decision-Making and End-of-Life Care
Challenges and Some of the Potential Solutions to Delivering Patient and Family Centered Care
The Patient Perspective (Ken Burkhom)
What the Bedside Nurse Sees (Erin Strong)
How the ICU Team Adapts (Jackie Guiliani, Preeti John)
Addressing the Repercussions of “Social Distancing”
Requests for inappropriate care, managing conflict (Alex Kon)
Shared decision making, care at the end of life & Social justice considerations (Giora Netzer)
Impact of contingency, crisis operations on communication challenges (Mary Faith Marshall)

Curriculum Topic: Shared Decision-Making and End-of-Life Care
Managing Health Disparities in the Setting of Triage Decisions
Julia F. Taylor, MD, MA, HEC-C from the University of Virginia presents on the topic of Health Disparities; Katherine Fischkoff, MD from Columbia University presents on Resource Allocation; and Erin S. DeMartino, MD from Mayo Clinic presents on Pandemic Planning. 

Curriculum Topic: Shared Decision-Making and End-of-Life Care
COVID Associated Acute Kidney Injury (AKI)
Dr. Marlies Ostermann from Guy’s & St. Thomas’ NHS Foundation Hospital in London, UK, who covered the evaluation and management of acute kidney injury in patients with COVID-19, including a review of the COVID ADQI Work Group AKI consensus report. 

Curriculum Topic: Fluids, Electrolytes, and Acute Kidney Injury
Arterial Ischemia in COVID-19; Is Ischemic Stroke More Prevalent with COVID?
Dr. Daniel Temas from Prisma Health will present a case study presentation.  Paul Nyquist, MD,  from MPH, the Johns Hopkins University School of Medicine, will provide an update on Stroke literature related to COVID and speak to thrombosis and Ischemic stroke impact. 

Curriculum Topic: Cardiovascular Complications: Venous Thromboembolism, Myocarditis, and Shock
Multisystem Inflammatory Syndrome in Children
Update on research and evidence in multisystem inflammatory syndrome in children. This is SCCM curated COVID-19 microlearning content.

Curriculum Topic: Cardiovascular Complications: Venous Thromboembolism, Myocarditis, and Shock
VTE and COVID-19; Anti-Xa Monitoring in VTE Prophylaxis: Is There a Role?
Controversies in VTE Prophylaxsis; Xa Monitoring for VTE Prophylaxis. This is SCCM curated COVID-19 microlearning content.

Curriculum Topic: Cardiovascular Complications: Venous Thromboembolism, Myocarditis, and Shock
COVID-19 Persistent and Recurrent Symptoms
Viral Shedding and complications with data interpretations; Case presentation from Concord Hospital - Laconia. This is SCCM curated COVID-19 microlearning content.

Curriculum Topic: Infectious Complications & Management of COVID-19 Infection / Nosocomial
Infectious Complications of COVID-19; Infection Control in COVID-19
Infection Control and healthcare-associated infections (HAIs) during COVID-19. This is SCCM curated COVID-19 microlearning content. 

Curriculum Topic: Infectious Complications & Management of COVID-19 Infection / Nosocomial
Treatments of Moderate and Severe COVID-19 Pneumonia

Antiviral and Immunomodulatory Therapies for COVID-19. This is SCCM curated COVID-19 microlearning content.

Curriculum Topic: Infectious Complications & Management of COVID-19 Infection / Nosocomial