COVID-19: What’s Next: A Deeper Dive into Top Sessions

COVID-19: What’s Next, the first-of-its kind virtual conference hosted by the Society of Critical Care Medicine (SCCM), featured the newest research findings, epidemiologic models, and guideline updates for caring for patients with COVID-19 from specialists on the front lines.
 
With 13 sponsoring societies and more than 20 endorsing societies, the conference represented unprecedented collaboration by the critical care community as healthcare systems and professionals prepare for the convergence of COVID-19 and the flu season.
 
The conference began with an address by Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), on advances in diagnosis, therapies, and vaccine research, followed by a presentation of updates from Discovery’s VIRUS COVID-19 Registry of more than 18,000 hospitalized patients from 21 countries. Adm. Brett P. Giroir, MD, assistant secretary for health at the U.S. Department of Health and Human Services, gave the closing plenary session, speaking about accessing federal resources and planning for the future by building multiprofessional teams.
 
Here are some highlights of six of the top educational presentations from critical care leaders and their key take-aways.

Leading During a Pandemic: Partnerships for Solutions

ADM. Brett P. Giroir, MD, Assistant Secretary for Health, U.S. Department of Health and Human Services
 
[Preview] When the pandemic reached the United States, we knew COVID-19 diagnostic testing efforts were critical and that we needed to act quickly and strategically. Therefore we established community-based testing sites in socially vulnerable locations across the country to meet short-term testing needs. It was crucial that we not exhaust the Strategic National Stockpile of PPE, so the plan was to expand the stockpile and develop new PPE-sparing technologies so we could focus on developing advanced testing.
 
Through July 31, we had 41 federally supported sites in 12 states, testing more than 400,000 individuals. This eventually turned into a nationwide 50-state community-based testing site program, with more than 800 pharmacy partners and testing more than 1.8 million people.
 
We continue to improve the national testing strategy as we prepare for the second wave of COVID-19. Here is what we aim to accomplish:

• Identify newly emergent outbreaks to facilitate community mitigation measures and allocations of national resources
• Support public health isolation and contact tracing to control community spread
• Diagnose COVID-19 rapidly in hospitalized patients to accelerate treatment and/or enrollment in clinical trials
• Protect vulnerable people to minimize morbidity and mortality
• Support safe reopening of schools and businesses by implementing a surveillance network that does not impede the clinical diagnostics system
• Enable state testing plans to achieve overall national objectives as well as state-specific goals

Traditional testing and tracing will not solve all of our pandemic problems since asymptomatic spread is still a huge threat. The best thing we as a society can do is to follow the three important W’s:

• Wear a mask
• Watch your distance
• Wash your hands

As for medical professionals on the front lines, it is important to participate and engage with government officials. Things are not solved behind the walls of Washington, DC; they are solved on the front lines of the pandemic. We must work together, while leading with empathy for all those with the disease.

 

Implementing Crisis Standards of Care: Allocating Scarce Resources

Ryan C. Maves, MD, FCCP, FIDSA, FCCM, Infectious Diseases and Critical Care Medicine Naval Medical Center, San Diego, California, USA, and Associate Professor of Medicine, Uniformed Services University
 
[Preview] Hospitals do not exist in a vacuum. Coordination between institutions during a crisis allows for minimal impact on each institution. The COVID-19 pandemic required implementation of crisis standards of care (CSC)—an adaptation of clinical standards of care during a public health crisis or emergency—in regions that experienced a surge. The United States is in a chronic contingency state, during which adapting and conserving resources is necessary.
 
CSC does not mean providing less care to patients, deciding who will live and die, or reducing our ethical burden to our patients, to each other, and to society. Rather, the goal of CSC is to do the best possible job of meeting standards of care in a difficult situation.
 
When developing CSC, resource allocation is critical. Resources are organized into three categories, all encompassed under systems and communications/command control:
 
Stuff:

• Ventilators, dialysis machines, associated consumables
• Medications
• Personal protective equipment (PPE)

Staff:

• Acute care-trained physicians, nurses, nurse practitioners, physician assistants, respiratory therapists, pharmacists, and emergency medical services
• Other critical supporting staff who may be personally impacted

Space:

• Physical ICU and ward beds
• Alternate sites of care
• Airborne infection isolation room availability

 
When demand exceeds supply, public health control measures should be implemented. During times of extreme need, triage principles must be followed. Resource adjustments and use of command control communication helps mitigate the impact on any one institution.
 
For surge plans to be effective, care needs to be regionalized, with robust communication among healthcare systems. Some institutions created integrated systems among competing health systems, allowing for the movement of patients and supplies to blunt the impact of the crisis. This is not possible without a mechanism for health systems to communicate regularly, which is why it is so important to devise a plan.
 
A crisis care committee should comprise clinicians, nurses, and administrators experienced in critical care who would make objective decisions independently of those directly caring for patients.

 

Invasive or Noninvasive Support: When, Where, and How

Meghan B. Lane-Fall, MD, MSHP, FCCM, Penn Medicine

[Preview] When treatment of patients with COVID-19 began, initial guidance was to intubate everyone with respiratory insufficiency because of concerns about aerosolization. As healthcare professionals become more comfortable with infection control and as the poor outcomes for intubated patients became evident, they moved to more noninvasive support.

Invasive respiratory support includes:

• Endotracheal intubation
• Tracheostomy
• Extracorporeal membrane oxygenation (usually venovenous)

Forms of noninvasive respiratory support include:

• Continuous positive airway pressure and bilevel positive airway pressure
  • Nasal pillows
  • Mask
  • Helmet
• High-flow nasal oxygen

Healthcare professionals should consider a number of factors in determining whether invasive or noninvasive support would be most beneficial.
 
Factors that favor noninvasive ventilation:

• Stable high oxygen requirements
• Normal mental status
• Limitations to where patients are cared for on a ward
• Moderate to severe COVID-19

Factors that favor invasive ventilation:

• Rapid deterioration
• Severe to critical COVID-19
• Altered mental status
• Inability to protect airway
• Copious secretions
• Severe respiratory acidosis
• Hypopnea or apnea
• Shock
• Inability to tolerate noninvasive support

When intubating a patient, protecting yourself and other healthcare professionals from aerosols is important. Therefore, you should:

• Intubate under controlled conditions
• Have the most experienced operator perform the procedure
• Don full PPE, including an N95 mask or something more extensive such as a face shield or powered air-purifying respirator. The mouth, nose, and eyes should be completely covered.
• Adjuncts can be used to protect clinicians during airway procedures.

Remember, cardiopulmonary resuscitation also is an aerosolizing procedure and it is important for clinicians to protect themselves. The number of staff in the room should be minimized and proper PPE must be worn, even if it delays patient care.

 

What Is New in Diagnostic Testing?

Greg S. Martin, MD, MSc, FCCM, Professor and Executive Associate Division Director, Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine; Co-director, Atlanta Center for Microsystems Engineered Point-of-Care Technologies; President-Elect, Society of Critical Care Medicine
 
[Preview] Testing for SARS-CoV-2 is the key to reducing spread of the virus and getting the United States on the path to restoration, especially by identifying asymptomatic patients. Currently the United States tests about 750,000 people daily, but we need to reach 4.3 million daily by this fall, according to the Rockefeller Foundation.
 
Tests for active infection include the nucleic acid amplification test (NAAT) (RNA test, reverse transcriptase polymerase chain reaction [RT-PCR]), which is highly accurate and delivers results in hours to days, and the antigen test, which delivers results in minutes to hours, although negative results may need to be confirmed with NAAT.
 
As of mid-August, 140 COVID-19 tests have received FDA early use authorization. To ramp up testing capability of active infection, the National Institutes of Health (NIH) launched the Rapid Acceleration of Diagnostics (RADx) initiative. One of its four components, RADx Tech, accelerates development and deployment of innovative technologies.
 
To date, 3000 tests have been submitted and are being evaluated through five centers that are part of the NIH Point-of-Care Technologies Research Network. As of mid-August, 686 submissions have made it through the viability phase, and about half of these have come from small businesses. Tests in the pipeline include:

• NAAT tests for SARS-CoV-2 RNA focusing on:
  • Improvements on standard RT-PCR
  • Isothermal amplification
  • CRISPR-based
  • Next-generation sequencing
• Tests for detection of SARS-CoV-2 antigens:
  • Lateral flow assays

The sample tissues include saliva, oral swabs, nasal swabs, sputum, and blood. Each are developed for specific use and are being tested in those environments, from large-scale settings such as universities and airports to restaurants, drive-through sites, and home testing.

 

Best Practices in Parallel Care: COVID-19 and Non-COVID-19 Patients

Gopi Patel, MD, MS, Hospital Epidemiologist, The Mount Sinai Hospital, New York, New York, USA; Associate Professor, Department of Medicine
 
[Preview] When determining risk mitigation, we often refer to the hierarchy of hazard controls ranked from most effective to least effective: elimination, substitution, engineering controls, administrative controls, PPE. However, this hierarchy is not always applicable to infectious diseases. This is why it is essential to have a pandemic plan in place.
 
When COVID-19 erupted, we immediately diverted resources from routine operations toward increasing capacity to treat COVID-19 patients. This included:

• Deferring nonurgent visits and halting or reducing the volume of elective surgical procedures
• Discouraging use of resources for asymptomatic and mildly ill patients
• Deploying staff and encouraging work from home
• Restricting visitors
• Ramping up telemedicine

As for parallel care, we prioritized single patient rooms for patients colonized or infected with multidrug-resistant organisms and with confirmed COVID-19. Patients with suspected COVID-19 but with delayed or negative test results were prioritized to single patient rooms on non-COVID-19 units or in some cases  units specifically for people under investigation.
 
As we prioritized caring for COVID-19 patients, we all wondered: Where did the non-COVID-19 patients go? In the 10 weeks following the declaration of the COVID-19 national emergency, visits to emergency departments declined for heart attack (23%), stroke (20%) and uncontrolled high blood sugar (10%). The deferral of services and complications interrupted healthcare, and we were forced to address medical concerns and stigma and maintain capacity for a potential influx.
 
Healthcare worker management was also a cornerstone of the pandemic response. To provide safe, parallel care, we increased daily screening of staff for symptoms and exposures, hosted daily briefings, held “elbow bump” rounds, addressed PPE fatigue, and discussed overall patient perception.
 
Looking ahead, we know that:

• Local epidemiology, testing capacity, tracing capacity, and pretest probability will determine thresholds to roll back and ramp up efforts.
• We will be dealing with the consequences of interrupted care and the upcoming flu season.
• Hand washing, masking up, social distancing, and PPE work.
• Everyone is someone’s loved one.

We have learned so much since the start of the pandemic, yet we still have so much more to learn.

 

Pre-ICU Oxygenation of COVID-19 Patients: The Role of Awake Proning

Nicholas A. Bosch, MD, MSc, Assistant Professor of Medicine, Boston University School of Medicine Boston, Massachusetts, USA
 
[Preview] Over the years, research has shown that prone positioning of mechanically ventilated patients improves oxygenation and mortality in patients with more severe acute respiratory distress syndrome. We also know these outcomes likely depend on expertise and proning duration.
 
We have less robust literature on prone positioning of awake patients with COVID-19. There have been only three cohort studies, which measured oxygenation before and after prone positioning.
 
We know that awake proning appears to improve oxygenation in more severely ill COVID-19 patients, but these patients also are at higher risk for worse outcomes from delayed intubation. And because our experience of this type of care is limited to the past nine months, there are many things we do not know, including:

• What severity of illness is most appropriate for proning?
• Do COVID-19 phenotypes play a role?
• What is the appropriate level of monitoring?
• Who should initiate it?
• What should the duration be?
• When should it be initiated?
• When should it be stopped?
• What are the clinical outcomes?

Further, although prone positioning sounds innocuous, it has real potential for harm, including:

• Patient self-inflicted lung injury and delayed intubation
• Arrhythmias
• Disruption of indwelling catheters
• Pressure sores
• Discomfort

Because of the dearth of evidence, most organizations are making no recommendations on awake proning of COVID-19 patients. We all want to help patients, but we also need to be aware that we often are biased to believe the things we give patients help them and do not harm them.
 
Several clinical trials are in process that hopefully will shed more light on this, and we need to wait for their results to learn whether awake prone positioning of COVID-19 patients truly is beneficial and, if so, which patients would be most likely to benefit.