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STOP-VIRUS ICU Learning Collaborative

Focused on improving outcomes for patients with COVID-19.

This project has concluded.

The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 (STOP-VIRUS) Learning Collaborative was a six-month initiative focused on improving outcomes for patients with COVID-19. This site previously provided updates and learning materials for best practices from the collaborative, which brought together U.S. hospitals participating in the SCCM Discovery VIRUS Registry. Applications to join the collaborative are no longer being accepted, and the program has officially concluded.

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 provided 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.

Key Focus Areas of the STOP-VIRUS Curriculum:

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

The collaborative featured weekly Zoom sessions where subject matter experts delivered state-of-the-art updates for each curriculum topic area. These updates included summaries of COVID-19 best practices and reviews of current literature. Implementation experts also helped nurture the learning community and provided advice on best practices for local site dissemination and implementation efforts. Participants engaged in ongoing dialogue with subject matter experts and faculty through various platforms, including the hashtag #STOPVIRUScollab on X.

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). Its contents do not necessarily represent the policy of the CDC or HHS and should not be considered endorsement by the Federal Government.

Although the collaborative has concluded, the resources and insights it generated continue to contribute to the improvement of ICU processes and patient outcomes.

STOP-VIRUS Collaborative Participating Sites

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

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STOP-VIRUS Collaborative Participating Sites

Baltimore, Maryland, USA
Ascension Saint Agnes Hospital

Anthony Martinez, MD
Dean Meadows, MD
Helen Stinnett, BA, RRT
Olubukola Adeyemi, PharmD
Terry Herbert, BSN, RN

Brigham and Women’s Hospital
Boston, Massachusetts, USA

Gerald L. Weinhouse, MD
Namrata Patil, MD, MPH
Gaspar Hacobian, PharmD, BCPS

Concord Hospital - Laconia
Laconia, New Hampshire, USA

Kamen Rangelov, MD
Jillian Parker, RRT
Michael P. Smith, PharmD, BCCCP
Rachel Smith, RN, MSN, MBA, CCRN

Howard University Hospital
Washington, DC, USA

Norma M. Smalls-Mantey, MD, FACS, MBA, FCCM

Mayo Clinic Children’s Center
Rochester, Minnesota, USA

Emily Davis, RN, CCRN
Grace M. Arteaga, MD, FAAP, FCCM
Jennifer L. Fleegel, RN, CCRN
Julie M. Duncan, RN
Kevin K. Graner, RPh
Tammy J. Schultz, RRT, LRT

Mayo Clinic Eau Claire
Eau Claire, Wisconsin, USA

Abigail La Nou, MD, FACEP
Adeel Rishi, MD
Christina Hall, MS, RN
Cindy Christensen, MSN, RN, FNP-BC
Kirsten Holbrook, RRT
Sara Toufar, PharmD, RPh
Sarah Normand, PharmD, RPh

Mayo Clinic Florida
Jacksonville, Florida, USA

Abhishek Giri
Ashley Gill, RRT
Catherine L. Mielke, MS, APRN, CNS
Devang Sanghavi, MD, MHA
Jonathan K. Clark, RRT
Julie Shimp, RN
Lisa Marshall, MSN, RN
Michael Spiros, MSN, RN
Nirmaljot Kaur
Sean P. Kiley, MD
Siva Naga Yarrarapu, MBBS
Teresa Keister, RN

Mayo Clinic Mankato
Belle Plaine, Minnesota, USA

Gage Stroope, LRT, CRT
Jackie Stark, PharmD, BCPS
Jessica Poehler, RN
Juan Pablo Domecq Garces, MD
Nitesh Kumar Jain, MD, MBBS
Syed Anjum Khan, MD
Thoyaja Koritala, MD

Mayo Clinic Rochester
Rochester, Minnesota, USA

Amy Spitzner, RN, CCRN
Carissa Quinn, APRN, CNS, DNP
Christina Xia, PharmD, BCCCP
Holly D. Behrns, LRT, RRT
Jennifer Elmer, APRN, CNS, DNP
Sarah Chalmers, MD, PCCM,

OSF Children’s Hospital of Illinois Saint Francis Medical Center
Peoria, Illinois, USA

Aaron Harthan, PharmD, BCPPS
Edmundo A. Martinez, MD
Jennifer A. Bandy, RN, BSN
John Sanford, RRT-ACCS, RRT-NPS
Jackie A. Guiliani, BSRT, RRT-NPS
Megan Kupferschmid, MSN, RN, P-CCRN

Prisma Health
Columbia, South Carolina, USA

Anand Pariyadath, MD
Brandy Vitielliss, BSN, RN
Daniel Temas, MD
Smith F. Heavner, MS, RN, PCCN

Valleywise Health
Phoenix, Arizona, USA

Amanda Frary, MSN, RN
Murtaza Akhter, MD
Rania Rahman, MD
Mary Mulrow, RN, MN, CCRP
Tracy Cooper, RN

Faculty

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

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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.

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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.

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STOP-VIRUS Subject Matter Experts

Subject matter experts are distinguished experts on the curriculum topics: respiratory failure in the COVID-19 patient; ICU Liberation Bundle implementation; infectious complications and management of COVID-19 infection, nosocomial; cardiovascular complications; fluids, electrolytes, and acute kidney injury; shared decision-making and end-of-life care.

Aaron B. Holley, MD
Walter Reed National Military Medical Center
Washington, DC, USA

Alexander A. Kon, MD, MS
University of Washington
Seattle, Washington, USA

Amita Avadhani, PhD, DNP, CNE, DCC, ACNP-BC, NP-C, CCRN, FAANP, FCCM
Rutgers University School of Nursing
Newark, New Jersey, USA

Amy L. Dzierba, PharmD, FCCP, BCCCP, FCCM
New York-Presbyterian Hospital
New York, New York, USA

Andre C. Kalil, MD, MPH, FACP
University of Nebraska Medical Center
Omaha, Nebraska, USA

Ashley D. DePriest, MS, RDN, CNSC
Wellstar Health System
Atlanta, Georgia, USA

Bradley Peters, PharmD, RPh, BCSP, BCCCP
Mayo Clinic
Rochester, Minnesota, USA

Brenda T. Pun, DNP, RN, FCCM
Vanderbilt University Medical Center
Nashville, Tennessee, USA

Courtney E. Bennett, DO
Mayo Clinic
Rochester, Minnesota, USA

Eric Kriner, BS, RRT
Medstar Washington Hospital Center
Washington, DC, USA

Erin S. DeMartino, MD
Mayo Clinic
Rochester, Minnesota, USA

Erin Strong, BSN, RN, CCRN
University of Pennsylvania
Philadelphia, Pennsylvania, USA

Giora Netzer, MD
University of Maryland School of Medicine
Baltimore, Maryland, USA

Greg S. Martin, MD, MSc, FCCM
Emory University School of Medicine
Atlanta, Georgia, USA

Jerry J. Zimmerman, MD, PhD, FCCM
Seattle Children’s Hospital
Seattle, Washington, USA

Julia Taylor, MD, MA, HEC-C
University of Virginia
Charlottesville, Virginia, USA

Karen A. Korzick, MD, MA, FCCP, FACP, FCCM
Geisinger Medical Center
Danville, Pennsylvania, USA

Katherine Fischkoff, MD, MPA, FACS
Columbia Presbyterian Hospital
New York, New York, USA

Kelly Cawcutt, MD, MS, FACP, FIDSA
University of Nebraska Medical Center
Omaha, Nebraska, USA

Lewis J. Kaplan, MD, FACS, FCCM
University of Pennsylvania
Philadelphia, Pennsylvania, USA

Marlies Ostermann, MD, PhD
Guy’s and St. Thomas’ NHS Foundation Trust
London, United Kingdom

Mary Susan Gaeta, MD, FACP
University of Texas MD Anderson Cancer Center
Houston, Texas, USA

Mary Faith Marshall, HEC-C, PhD
University of Virginia School of Medicine
Charlottesville, Virginia, USA

Nahreen Ahmed, MD, MPH
University of Pennsylvania
Philadelphia, Pennsylvania, USA

Paul Alan Nyquist, MD, MPH
Johns Hopkins School of Medicine
Baltimore, Maryland, USA

Pooja A. Nawathe, MD, FAAP, CHSE-A, CHSOS, FCCM
Cedars-Sinai Medical Center
Los Angeles, California, USA

Preeti R. John, MD, MPH, FACS, CPE, HEC-C
VA Maryland Health Care System
Baltimore, Maryland, USA

Uzma Syed, DO, FIDSA
Good Samaritan Hospital Medical Center
Long Island, New York, USA

Curriculum Topics

Approach to Respiratory Failure

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.

Resources

High-Flow Nasal Cannula Oxygen/Noninvasive Ventilation

Awake Prone Positioning

Awake Prone Positioning for COVID-19 Acute Hypoxaemic Respiratory Failure: A Randomised, Controlled, Multinational, Open-Label Meta-Trial

Scoring Systems

Mechanical Ventilation and Prone Positioning in Adults With ARDS

ICU Liberation Bundle (A-F)

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

Infectious Complications and Management

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.

Resources

Surviving Sepsis COVID-19 Guidelines

Cardiovascular Complications

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.

Resources

Anticoagulation in COVID-19

MISC-C

Multi-System Inflammatory Syndrome in Children & Adolescents (MIS-C): A Systematic Review of Clinical Features and Presentation

Shared Decision-Making and End-of-Life Care

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.

Fluids, Electrolytes, and Acute Kidney Injury

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.

Resources

Quality Improvement and Implementation

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.