In the preliminary analysis of the VIRUS COVID-19 Registry of Discovery, the Critical Care Research Network, investigators discovered significant variations in mortality that were not readily explained by patient comorbidities, demographics, or severity of illness. It became evident that much of the disparity in outcomes was tied to variations in processes of care from one intensive care unit (ICU) to another.
“All things considered, process variations were not surprising early in the pandemic,” said Alexander S. Niven, MD, core faculty for the collaborative and consultant with the Division of Pulmonary and Critical Care Medicine at Mayo Clinic, Rochester, Minnesota. “SARS-CoV-2 was a brand new virus, and healthcare teams were forced to apply the information that was readily available in the face of an overwhelming surge in cases. The patient volume also forced hospital systems to bring in many staff who did not regularly practice in the ICU to provide care.”
STOP-VIRUS leaders set out to address these variations and ensure a more effective response moving forward by creating a learning collaborative in a virtual setting. Sponsored by the Society of Critical Care Medicine (SCCM) and supported by the Centers for Disease Control and Prevention (CDC), STOP-VIRUS launched in April as a six-month program. Participation was open to all U.S. and U.S. territory hospitals currently participating in the VIRUS registry that had entered at least three to six months of data. Twelve hospitals are participating.
Effectively managing very ill patients, including those with COVID-19, requires a standardized, systemic, and structured approach. Multiprofessional members from each STOP-VIRUS institution completed
online modules using Mayo Clinic’s Checklist for Early Recognition and Treatment of Acute Illness and Injury (
CERTAIN) program during the first 30 days of the collaborative. Launched in 2013, CERTAIN has proven effective at improving ICU processes and patient outcomes in a prospective quality improvement (QI) intervention at 34 ICUs across 15 countries. STOP-VIRUS participants were asked to follow the CERTAIN admission and rounding checklists and to employ patient- and family-shared decision-making tools and strategies to humanize the critical care environment and ensure consistent, patient-centered decision-making. They also were encouraged to begin using a COVID-specific ICU
checklist and conduct a safety culture survey to better understand the teamwork and culture within the ICU.
While outcomes are not expected until the end of the year, at three months many participants reported that they had shared information from the weekly STOP-VIRUS state-of-the-art summaries and discussions in leadership meetings. Several reported that they are actively working on a variety of QI projects related to the management of respiratory failure, prevention of nosocomial complications, and strengthening patient and family communication regarding goals of care based on data provided by the VIRUS Registry. STOP-VIRUS leaders are encouraging participants to report their own findings.
“Previously people didn’t think this could be done virtually, but COVID forced us to think differently, and we’ve shown it can work,” said Yue Dong, MD, STOP-VIRUS core faculty and assistant professor of medicine at Mayo Clinic. “We’ve learned a lot from members of hospitals of various sizes and settings and from different members of the multidisciplinary team—we’ve been learning together. The Zoom-based videoconference plus online engagement with Blackboard and Twitter (blended learning) helps build the community we all seek to improve daily care for patients.”
STOP-VIRUS focuses on providing high-quality education by creating a robust network within SCCM to summarize and deliver the best current understanding to participants. It also provides a learning community and framework to help centers establish and effectively implement QI practices.
Because effective multidisciplinary care proved to be vital during the pandemic, applicants were asked to choose a nursing leader, physician leader, pharmacist, and respiratory therapist to participate in the weekly one-hour calls via Zoom. The calls feature subject matter experts delivering state-of the-art updates on one of six curriculum topic areas (based on a preprogram member needs assessment survey) and include a summary of the latest COVID-19 best practices and literature. Implementation experts offer advice on disseminating and implementing these best practices. The collaborative also often employs smaller breakout groups to maximize the opportunity to share experiences; the breakout groups then share their learnings and discussions with the larger group
via Twitter with the #STOPVIRUScollab hashtag.
Based on the preliminary findings of STOP-VIRUS, the six curriculum topics are:
- Approach to Respiratory Failure in the COVID-19 Patient
- While noninvasive respiratory support is sufficient for some, invasive mechanical ventilation is necessary for many patients with COVID-19 acute respiratory distress syndrome (ARDS). Various strategies have been used to optimize the decision and timing of intubation, including formal scoring systems.
- Adherence to lung-protective mechanical ventilation and prone positioning remains suboptimal among patients treated with invasive mechanical ventilation. One of the STOP-VIRUS pilot QI initiatives is focused on accurate electronic health record charting of plateau pressures to provide better real-time decision support to bedside clinicians.
- ICU Liberation Bundle (A-F): Implementation and Challenges
- ICUs in the collaborative encountered challenges in adhering to the ICU Liberation Bundle with increased use of deep sedation, absence of family visitation and consequent increase in delirium, prolonged mechanical ventilation, and post-intensive care syndrome. Best practices across the collaborative were identified as use of two-way video devices, more liberal visitation policies in pediatric ICUs, multimodal pain and sedation regimens guided by ICU pharmacists, and the key roles of occupational and physical therapy. At the peak of the pandemic, medication and personal protective equipment (PPE) shortages posed additional challenges.
- QI interventions included family participation on rounds via phone or two-way video and increased use of interpreters.
- Infectious Complications and Management of COVID-19
- Misinformation has been a constant challenge throughout the COVID-19 pandemic. Thankfully, large pragmatic randomized clinical trials rapidly defined the treatments supported by evidence that are used across the collaborative, including antiinflammatory (corticosteroids) and antiviral agents. The prolonged course of respiratory failure occurring in many COVID-19 patients and constraints related to PPE have led to yet another epidemic—there has been an unprecedented rise in ICU-acquired infections. A multiprofessional rounding process with a checklist approach such as CERTAIN is an effective solution to ensure appropriate review and removal of central venous, arterial, and urinary catheters.
- Another ongoing pilot QI intervention within the collaborative is to improve adherence to oral care in patients with respiratory failure to prevent ventilator-associated events.
- Cardiovascular Complications: Venous Thromboembolism, Myocarditis, and Shock
- While meticulous adherence to venous thromboembolism prophylaxis is essential to prevent this otherwise common complication, therapeutic coagulation remains controversial and is not routinely recommended in critically ill patients with COVID-19. ICU pharmacists play an essential role in ensuring adequate dosing, particularly in patients with obesity or renal impairment. Some ICUs have used factor Xa measurements to guide prophylactic and therapeutic dosing.
- Shared Decision-Making and End-of-Life Care
- Restrictive family presence policies have posed significant challenges to the development of therapeutic relationships and shared decision-making. Early palliative care involvement has been very helpful and is a focus of a formal QI intervention in both adult and pediatric ICUs within the collaborative. Understanding that palliative care does not equal end-of-life care is critical, and educational efforts are planned to reinforce these concepts with patients, families, and ICU staff. The CERTAIN approach, which uses a “Get to Know Me” board to bring critically ill patients from anonymity and humanize the care they receive, has been used in several institutions.
- Fluids, Electrolytes, and Acute Kidney Injury
- While causes of acute kidney injury in COVID-19 patients are multiple and not fully understood, the key prevention strategies remain: optimizing kidney perfusion pressure, avoiding fluid overload and nephrotoxic agents, and adjusting medications according to renal function. Careful and collaborative planning to ensure that dialysis resources can meet clinical demands proved important during periods of surging patient volume early in the pandemic.
Leaders noted that, to truly implement change, it is vital for participants to look at their own data, identify suboptimal areas of care, and then address these problems with specific quality interventions.
For example, one center found that the rate of palliative care consultation was low in their COVID-19 population, even in patients with high acuity and multiple comorbidities. As a result, these collaborators are developing a QI intervention that engages palliative care experts early in ongoing goals-of-care conversations with these patients. Many COVID-19 patients experience profound hypoxemic respiratory failure, requiring a prolonged course of mechanical ventilation. Other sites are working to ensure consistent application of evidence-based best practices including daily spontaneous awakening trials, lung-protective ventilation for ARDS, and early device removal when possible to reduce the risk of nosocomial infections.
While it is too early to demonstrate patient outcomes improvement, STOP-VIRUS leaders are confident that this innovative approach is not only beneficial but also scalable to other sites and similar QI programs.
“What is unique is that the registry provides an infrastructure for data collection that will go beyond this pandemic, helping pave the way for a smoother process for future interventions,” said Ognjen Gajic, MD, FCCM, Division of Pulmonary and Critical Care Medicine at Mayo Clinic, and STOP-VIRUS core faculty and consultant. “We can extend the learning community so more patients can benefit. With the ongoing efforts toward fully automated, standardized data collection from electronic health records, the SCCM VIRUS registry will provide sustainable infrastructure for benchmarking, pragmatic trials, and quality improvement interventions.”
Other sites interested in improving their COVID-19 and future responses can access STOP-VIRUS materials on the
STOP-VIRUS ICU Learning Collaborative site.
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