Clinical Care of COVID-19 Patients in a Front-line ICU

Robert A. Raschke MD

Tyler J. Glenn MD

Kim I. Josen MD

HonorHealth Scottsdale Osborn Medical Center

Scottsdale, AZ USA

These are some clinical observations made after over the past 10 months, working in a busy COVID-19 ICU unit in Scottsdale, AZ. The opinions expressed here are those of the private practice authors.

Overview of triage and rounding on large numbers of COVID-19 patients in the ICU service. Our approach to bedside care of our ICU service has required abbreviation for the sake of efficiency in the face of more than a doubling of our census. Our approach to rounding is opinion-based. We’ve been forced to evolve our triage and rounding systems in order to survive.

Our hospital uses the Abbott ID-Now® rapid point-of -are test for screening all COVID-19-asymptomatic patients admitted to our hospital, but due to its low sensitivity in hospitalized patients (1). We do not trust it to rule-out COVID-19 in patients with pneumonia being admitted to the ICU and also order an in-house PCR for such patients prior to, or upon ICU admission. We are cautious about transferring COVID-19 patients out of the ICU on bilevel positive airway pressure (BiPAP) or high-flow nasal cannula since many such patients have deteriorated and bounced-back to the unit within the subsequent week.

We try to see as many of our COVID-19 ICU patients (who are practically all our patients) sequentially, without interruption if possible, leaving our masks and gowns on continuously and moving quickly from room to room, changing only gloves between patients unless a bacterial pathogen that requires contact isolation has been identified. Little/no helpful information can be gleaned by entering the room of patient who is proned in a rotoprone bed. Such patients may only be supined for brief periods, sometimes in the middle of night shift; and discussion with the nurses regarding their physical exam findings during supine positioning is high yield. Auscultation of COVID-19 patients using isolation stethoscopes is seldom of value. Palpation of the neck/trunk for crepitus, neurological examination (especially in patients emerging from heavy sedation and/or supined after prolonged proning), and assessment of fluid status are high yield. We keep track of how many days the patient has received mechanical ventilation, the cumulative fluid balance (which sometimes gets very positive), and signs and lab values possibly related to complications of COVID-19 discussed below. The duration of antibiotics and sedation medications needs constant monitoring to avoid overuse. We do not routinely follow serial INR, ferritin, CRP, or D-dimer, since these do not affect patient management. We sometimes use BNP and procalcitonin to trigger further cardiac or infectious disease evaluations respectively. We do not treat isolated elevated procalcitonin with antibiotics, nor do we treat isolated d-dimer with therapeutic dose anticoagulation.

We have been conservative in our treatment of COVID-19, relying primarily on dexamethasone and usual evidence-based critical care practice. Over the course of the outbreak, our conservative approach has been validated; various hyped but off-label therapies (hydroxychloroquine, antirheumatic therapies, universal therapeutic anticoagulation) have failed to show benefit and possibly caused harm when subjected to evidence-based scrutiny (2,3). Benefits of remdesivir in patients with advanced respiratory failure seem unclear/minimal (4). Most of our patients present to the ICU in the second or third week of illness, already having developed IgG antibodies and therefore unlikely to benefit from convalescent serum or monoclonal antibodies.

Clinical course and management of respiratory failure. Many patients remain awake and able to tolerate spontaneous ventilation with non-invasive ventilation and/or high-flow nasal canula oxygen delivering high FiO2, for as long as two weeks before they either recover or require endotracheal intubation. Before the current outbreak, it was unusual to manage severely hypoxemic patients without intubation and mechanical ventilation. For COVID-19, it seems to be the norm, with intubation delayed until the last possible moment, as it is unclear that mechanical ventilation with its attendant complications (immobility, sedation, invasive support apparatus) offer any definite benefit. Once intubated, many patients seem to transition abruptly to refractory hypoxemia and hypercarbia, which previously would have made them candidates for Extracorporeal membrane oxygenation (ECMO) transfer. In one recent case, we requested ECMO evaluation for a patient prior to intubation, anticipating that he would deteriorate badly immediately thereafter. The consultant requested intubation before ECMO evaluation, and indeed, once intubated, the patient immediately became too unstable for uncannulated transfer. In general, the numbers of patients fulfilling historical criteria for ECMO consideration have greatly overwhelmed ECMO capacity.

We have tried several approaches to invasive mechanical ventilation, but each has drawbacks. Our primary mode of ventilation, pressure-regulated volume control, has sometimes resulted in high plateau and driving pressures as respiratory system compliance worsens. We’ve used pressure control ventilation in some patients to limit driving pressure, but this has led to unrecognized worsening of respiratory acidosis in some. We have managed several episodes of cardiac arrest due to uncontrolled combined respiratory and metabolic acidosis in COVID-19 patients being treated with permissive hypercapnia ventilation who subsequently developed acute renal failure. We are now trying airway pressure-release ventilation (APRV) as an optional approach in which we try to avoid proning and heavily sedating the patient, but aim for Richmond Agitation-Sedation Scale (RASS) of -1 to -2 and allow maintenance of spontaneous respiratory efforts by the patient during “T high”. It is not clear whether any of these approaches results in better clinical outcomes.

Our use of prone positioning has increased dramatically. Self-proning of awake patients receiving non-invasive mechanical ventilation or high-flow nasal canula oxygen has allowed some to survive episodes of severe oxygen desaturation and avoid intubation. We have extensively utilized proning in mechanically ventilated patients with PaO2/FiO2 <150. Several of our patients experienced cardiopulmonary arrest when briefly supined resulting in several fatalities. Consequently, we have learned to placed US-guided internal jugular central venous catheters and chest tubes in patients in proned and semi-proned positions. We have noted that at some point, prone positioning needs to be abandoned if the patient is ever going to recover, even if their PaO2/FiO2 ratio falls upon supine positioning. In such patients, supine positioning allows reduction of heavy sedation and resumption/improvement of spontaneous breathing efforts that may allow ventilator weaning to slowly proceed.

Complications of COVID-19 in the ICU. We have seen more barotrauma than previously described, some occurring during non-invasive ventilation prior to endotracheal intubation (5). Point of care chest ultrasonography has been instrumental in several cases in which anterior pneumothoraces were not clearly apparent on chest radiography, except perhaps as a deep sulcus sign, and also to rapidly rule-out pneumothorax as a cause of acute cardiopulmonary decompensation.

Hypotension requiring intravenous vasopressors is common (6). In many cases, it seems due to sepsis and sedation with propofol and/or dexmedetomidine. We have occasionally seen acute or chronic cardiomyopathy, but not as often as noted early in the pandemic (7). We have repeatedly diagnosed relative adrenal insufficiency later in the hospital course –after dexamethasone has been discontinued. Such patients commonly received etomidate during intubation which could possibly be contributory.

Bacterial co-infections are uncommon at presentation, consistent with published meta-analysis (8), and we do not routinely give antibiotics to all patients with COVID-19 pneumonia up front. Later in the course of mechanical ventilation, many patients experience recurrent fever, leukocytosis, elevated procalcitonin and/or worsening pulmonary status prompting endotracheal secretion and blood cultures and empirical antibiotics. We have commonly isolated a wide variety of potential bacterial pathogens from the respiratory secretions of such patients including methicillin-sensitive Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus aureus (MRSA), gram negative rods, some multi-drug resistant. We recently isolated carbapenem-resistant Enterobacter. It is uncertain whether these represent true cases of secondary pneumonia.

Coagulopathy related to COVID-19 is complex and increased risk of thrombosis and bleeding seem apparent (9). We administer enhanced prophylactic-dose anticoagulation to all our patients (typically 40mg enoxaparin every 12 hours in patients without morbid obesity or renal failure), but do not treat elevated d-dimers with therapeutic anticoagulation in the absence of documented venous thromboembolism (4). A minority of our patients have had documented venous thromboemboli prior to ICU admission and a few have had acute myocardial infarctions and strokes. We try to get CT angiography of the chest and doppler ultrasound of the lower extremities on all patients requiring mechanical ventilation. Bedside ultrasonography demonstrating acute right heart failure has been helpful in a few cases in which pulmonary emboli were suspected but the patient too unstable for CT angio or VQ scan. Three of our patients experienced CNS hemorrhages, two of which were fatal. Gastrointestinal bleeding is not uncommon.

Acute renal failure is common and complicates permissive hypercarbia, sometimes necessitating high dose bicarbonate infusions (6). Circuit thrombosis during dialysis is common, perhaps a manifestation of COVID-19 coagulopathy, and sometime necessitating therapeutic anticoagulation.

End of life issues. It is our impression that the mortality in intubated patients is higher this winter than it was previously in the pandemic. This might be because patients are receiving more aggressive therapy earlier in the course of illness, and often are only intubated after failing a prolonged course of non-invasive mechanical ventilation. Perhaps this selects treatment-unresponsive patients for intubation. Prognostication seems very difficult. We treated an 89-year patient with severe comorbidities who rapidly recovered after a 4-day course of mechanical ventilation and a 28-year-old previously healthy man who died despite receiving veno-venous ECMO. We have not found clinical scoring systems such as

Sequential Organ Failure Assessment (SOFA) to be helpful in prognosis, since many patients have isolated severe single organ dysfunction at the time of ICU admission, and therefore have similar SOFA scores – mostly comprised of points given for severe respiratory failure. Old-fashioned bedside common sense and family discussion still seem the best approach to determining code status. It is logistically difficult/impossible to safely administer CPR to some patients who are proned, especially those that are morbidly obese. We have told families that we are instituting limited code status (no CPR, no ACLS) in such situations, subsequently discussing resumption of full code status if/when the patient recovers enough to tolerate resumption of supine positioning.

Psychosocial issues. Incredible emotional injury is being experienced by patients’ families. Several of our patients come from families in which two or three primary relatives have already died from COVID-19. We called one patient’s wife to inform her that her husband had narrowly survived a prolonged arrest secondary to pneumothorax, interrupting her during her son’s funeral, who had died from COVID-19 pneumonia the previous week. Eventually, that family suffered the death of three primary relatives from COVID-19 over the course of three weeks.

We have tried to use cellular technology to help mitigate restricted family visitation, but it seems a poor substitute. Our nurses have had some patients make cell phone video messages to their loved ones before intubation – sometimes the last memory their families will ever have of them. We have held our cellphones by the ears of COVID-19 patients as they are dying so that their loved ones can say goodbye. It was heart-wrenching to hear a husband of 42 years sobbing uncontrollably over the phone, telling his dying wife that he loved her, and how much he’s going to miss her as we prepared to remove her endotracheal tube to let her die.

The nurses, respiratory techs and physicians have shown incredible bravery and self-sacrifice and outward morale is good. But all are suffering severe vicarious injuries the full effect of which may not be apparent for years to come. Much of the human connection previously so important to ICU practice has been lost – few of the patients can interact, and the families are generally not allowed to visit. We simply don’t have the time anymore to call them as often as we would like, and it’s unusual to call them with good news. We should plan for a future increase in PTSD and burn-out among healthcare providers.

We are grateful to have received my COVID-19 vaccination, and I was sincerely astounded by the organizational excellence of the vaccination event implemented by HonorHealth here in Phoenix. They did a very good job that will serve our entire vaccine-willing population in the coming months.

References

1. Basu A, Zinger T, Inglima K, Woo KM, Atie O, Yurasits L, See B, Aguero-Rosenfeld ME. Performance of Abbott ID Now COVID-19 Rapid Nucleic Acid Amplification Test Using Nasopharyngeal Swabs Transported in Viral Transport Media and Dry Nasal Swabs in a New York City Academic Institution. J Clin Microbiol. 2020 Jul 23;58(8):e01136-20. [CrossRef] [PubMed]
2. WHO Solidarity Trial Consortium, Pan H, Peto R, Henao-Restrepo AM, et al. Repurposed Antiviral Drugs for Covid-19 - Interim WHO Solidarity Trial Results. N Engl J Med. 2020 Dec 2:NEJMoa2023184. [CrossRef] [PubMed]
3. Salama C, Han J, Yau L, et al. Tocilizumab in Patients Hospitalized with COVID-19 Pneumonia. N Engl J Med. 2020 Dec 17. [CrossRef] [PubMed]
4. American Society of Hematology. COVID-19 Resources: COVID-19 and VTE/Anticoagulation: Frequently asked questions. Version 5.1 (last updated December 24, 2020). Available at: https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation (accessed 1/3/21).
5. Botta M, Tsonas AM, Pillay J, et al., PRoVENT-COVID Collaborative Group. Ventilation management and clinical outcomes in invasively ventilated patients with COVID-19 (PRoVENT-COVID): a national, multicentre, observational cohort study. Lancet Respir Med. 2020 Oct 23:S2213-2600(20)30459-8. [CrossRef] [PubMed]
6. Cummings MJ, Baldwin MR, Abrams D, et al. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study. Lancet. 2020 Jun 6;395(10239):1763-1770. [CrossRef] [PubMed]
7. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, Lee M. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020 Apr 28;323(16):1612-1614. [CrossRef] [PubMed]
8. Langford BJ, So M, Raybardhan S, Leung V, Westwood D, MacFadden DR, Soucy JR, Daneman N. Bacterial co-infection and secondary infection in patients with COVID-19: a living rapid review and meta-analysis. Clin Microbiol Infect. 2020 Dec;26(12):1622-1629. [CrossRef] [PubMed]
9. Helms J, Tacquard C, Severac F, et al., CRICS TRIGGERSEP Group (Clinical Research in Intensive Care and Sepsis Trial Group for Global Evaluation and Research in Sepsis). High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020 Jun;46(6):1089-1098. [CrossRef] [PubMed]
10. Hayek SS, Brenner SK, Azam TU, et al. In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study. BMJ. 2020 Sep 30;371:m3513. [CrossRef] [PubMed]

Cite as: Raschke RA, Glenn TJ, Josen KI. Clinical Care of COVID-19 Patients in a Front-line ICU. Southwest J Pulm Crit Care. 2021;22(1):11-15. doi: https://doi.org/10.13175/swjpcc070-20 PDF

Why Is It So Difficult to Get Rid of Bad Guidelines?

Reference as: Robbins RA. Why is it so difficult to get rid of bad guidelines? Southwest J Pulm Crit Care 2011;3:141-3. (Click here for a PDF version of the editorial)

My colleagues and I recently published a manuscript in the Southwest Journal of Pulmonary and Critical Care examining compliance with the Joint Commission of Healthcare Organization (Joint Commission, JCAHO) guidelines (1). Compliance with the Joint Commission’s acute myocardial infarction, congestive heart failure, pneumonia and surgical process of care measures had no correlation with traditional outcome measures including mortality rates, morbidity rates, length of stay and readmission rates. In other words, increased compliance with the guidelines was ineffectual at improving patient centered outcomes. Most would agree that ineffectual outcomes are bad. The data was obtained from the Veterans Healthcare Administration Quality and Safety Report and included 485,774 acute medical/surgical discharges in 2009 (2). This data is similar to the Joint Commission’s own data published in 2005 which showed no correlation between guideline compliance and hospital mortality and a number of other publications which have failed to show a correlation with the Joint Commission’s guidelines and patient centered outcomes (3-8). As we pointed out in 2005, the lack of correlation is not surprising since several of the guidelines are not evidence based and improvement in performance has usually been because of increased compliance with these non-evidence based guidelines (1,9).

The above raises the question that if some of the guidelines are not evidence based, and do not seem to have any benefit for patients, why do they persist? We believe that many of the guidelines were formulated with the concept of being easy and cheap to measure and implement, and perhaps more importantly, easy to demonstrate an improvement in compliance. In other words, the guidelines are initiated more to create the perception of an improvement in healthcare, rather than an actual improvement. For example in the pneumonia guidelines, one of the performance measures which have markedly improved is administration of pneumococcal vaccine. Pneumococcal vaccine is easy and cheap to administer once every 5 years to adult patients, despite the evidence that it is ineffective (10). In contrast, it is probably not cheap and certainly not easy to improve pneumonia mortality rates, morbidity rates, length of stay and readmission rates.

To understand why these ineffectual guidelines persist, one needs to understand who benefits from guideline implementation and compliance. First, organizations which formulate the guidelines, such as the Joint Commission, benefit. Implementing a program that the Joint Commission can claim shows an improvement in healthcare is self-serving, but implementing a program which provides no benefit would be politically devastating. At a time when some hospitals are opting out of Joint Commission certification, and when the Joint Commission is under pressure from competing regulatory organizations, the Joint Commission needs to show their programs produce positive results.

Second, programs to ensure compliance with the guidelines directly employ an increasingly large number of personnel within a hospital. At the last VA hospital where I was employed, 26 full time personnel were employed in quality assurance. Since compliance with guidelines to a large extent accounts for their employment, the quality assurance nurses would seem to have little incentive to question whether these guidelines really result in improved healthcare. Rather, their job is to ensure guideline compliance from both hospital employees and nonemployees who practice within the hospital.

Lastly, the administrators within a hospital have several incentives to preserve the guideline status quo. Administrators are often paid bonuses for ensuring guideline compliance. In addition to this direct financial incentive, administrators can often lobby for increases in pay since with the increase number of personnel employed to ensure guideline compliance, the administrators now supervise more employees, an important factor in determining their salary. Furthermore, success in improving compliance, allows administrators to advertise both themselves and their hospital as “outstanding”.

In addition, guidelines allow administrative personnel to direct patient care and indirectly control clinical personnel. Many clinical personnel feel uneasy when confronted with "evidence-based" protocols and guidelines when they are clearly not “evidence-based”. Such discomfort is likely to be more intense when the goals are not simply to recommend a particular approach but to judge failure to comply as evidence of substandard or unsafe care. Reporting a physician or a nurse for substandard care to a licensing board or on a performance evaluation may have devastating consequences.

There appears to be a discrepancy between an “outstanding” hospital as determined by the Joint Commission guidelines and other organizations. Many hospitals which were recognized as top hospitals by US News & World Report, HealthGrades Top 50 Hospitals, or Thomson Reuters Top Cardiovascular Hospitals were not included in the Joint Commission list. Absent are the Mayo Clinic, the Cleveland Clinic, Johns Hopkins University, Stanford University Medical Center, and Massachusetts General.  Academic medical centers, for the most part, were noticeably absent. There were no hospitals listed in New York City, none in Baltimore and only one in Chicago. Small community hospitals were overrepresented and large academic medical centers were underrepresented in the report. However, consistent with previous reports, we found that larger predominately urban, academic hospitals had better all cause mortality, surgical mortality and surgical morbidity compared to small, rural hospitals (1).

Despite the above, I support both guidelines and performance measures, but only if they clearly result in improved patient centered outcomes. Formulating guidelines where the only measure of success is compliance with the guideline should be discouraged. We find it particularly disturbing that we can easily find a hospital’s compliance with a Joint Commission guideline but have difficulty finding the hospital’s standardized mortality rates, morbidity rates, length of stay and readmission rates, measures which are meaningful to most patients. The Joint Commission needs to develop better measures to determine hospital performance. Until that time occurs, the “quality” measures need to be viewed as what they are-meaningless measures which do not serve patients but serve those who benefit from their implementation and compliance.

Richard A. Robbins, M.D.

Editor, Southwest Journal of Pulmonary and Critical Care

References

1. Robbins RA, Gerkin R, Singarajah CU. Relationship between the veterans healthcare administration hospital performance measures and outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
2. Available at: http://www.va.gov/health/docs/HospitalReportCard2010.pdf (accessed 9-28-11).
3. Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med. 2005;353:255-64.
4. Werner RM, Bradlow ET. Relationship between Medicare's hospital compare performance measures and mortality rates. JAMA 2006;296:2694-702.
5. Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, Smith SC Jr, Pollack CV Jr, Newby LK, Harrington RA, Gibler WB, Ohman EM. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006;295:1912-20.
6. Fonarow GC, Yancy CW, Heywood JT; ADHERE Scientific Advisory Committee, Study Group, and Investigators. Adherence to heart failure quality-of-care indicators in US hospitals: analysis of the ADHERE Registry. Arch Int Med 2005;165:1469-77.
7. Wachter RM, Flanders SA, Fee C, Pronovost PJ. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008;149:29-32.
8. Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM.  Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303:2479-85.
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353:1860-1.
10. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.

The opinions expressed in this editorial are the opinions of the author and not necessarily the opinions of the Southwest Journal of Pulmonary and Critical Care or the Arizona Thoracic Society.