Since the start of the COVID-19 pandemic, clinicians have needed to take alternative approaches to provide care for patients with the novel coronavirus.
In a presentation at the virtual U.S. News & World Report Health Care of Tomorrow event, health care providers from across the United States discussed their experiences during the pandemic and the innovative methods they have developed to care for their patients.
Elizabeth Malsin, MD, a pulmonary and critical care specialist at Northwestern Memorial Hospital in Chicago, spoke about performing a two-lung transplant on Mayra Ramirez, the first known U.S. patient to receive such a transplant due to COVID-19 illness.
“Certainly, I never thought that we would be seeing this with the COVID-19 pandemic,” Malsin said. “SAR-CoV-2 ravages the lungs like nothing we’ve ever seen in people that are otherwise healthy, people like Mayra.”
She noted that while her institution treated patients who required ventilation and ECMO for similar illnesses prior to the pandemic, these patients were rare. Now, she said, they have had 10 to 20 patients requiring these treatments at once, and other institutions across the U.S. are experiencing similar increases.
Malsin added that options like lung transplants — which her institution has now completed for seven patients with COVID-19 — and other treatments that have demonstrated efficacy in clinical trials have changed how she thinks about COVID-19 care in severely ill patients, but clinicians are still struggling to meet the needs of these patients.
“Not everyone can get a lung transplant, and so we’re still trying to work towards how we get outcomes as best as we can and really working towards thinking about what things will look like after the vaccine,” Malsin said.
‘Humanize’ ICU patients
Jessica Montanaro, MSN, RN, assistant nursing care coordinator in the medical-surgical trauma ICU at Mount Sinai Morningside Hospital, said her institution reinstated a program used prior to the pandemic in their ICU.
In the Back to Bedside program — which was started by the Accreditation Council for Graduate Medical Education as an effort to humanize critical care patients who are typically intubated and sedated — fellows spoke with families to get personal information that the patient could not provide themselves beyond their medical and physical conditions.
This information included things like patients’ nicknames and what they look like.
Montanaro said that once the COVID-19 pandemic hit New York City, the hospital decided to resume the program. Fellows set up rotations to call families of patients to continue to collect this information and posted it outside of patients’ rooms at a time when no visitors were allowed, which meant violations of HIPAA were avoided.
She said that the program provided comfort to families, letting them know that “as a medical team, we weren’t just focused on the physical, the medicine, the diagnosis, that we were really interested in the person — the human being — that was in that bed.”
Due to the current surge in COVID-19 cases, Esther Choo, MD, MPH, professor in the Center for Policy and Research in Emergency Medicine at Oregon Health & Science University, said that ERs are quickly becoming crowded and limitations on both ER and hospital beds are making it more difficult for patients to move through the ER.
This is because, Choo said, some double-occupancy rooms have become single occupancy, and loss of staff has meant that staffed beds — in addition to physical beds — are limited.
She said that hospital staffers, like the general public, are facing a child-care crisis because of school shutdowns, which makes it difficult for them to return full time.
Another challenge ERs are facing amid the surge in COVID-19 cases, Choo said, is the influenza season and the influx in patients it could bring with it after the holidays.
“This has been a very dynamic pandemic, and in the ER, we’re definitely entering a different phase,” she said. “This is no longer a thing where we’re all watching New York, but all of us are feeling the crunch now.”
However, she said that while certain factors such as treatment decisions, prevention measures and triaging patients have become easier in ERs because of their experience with COVID-19, issues surrounding capacity and shortages of personal protective equipment remain.
Choo said that she and others started the nonprofit “Get us PPE” to help provide needed materials such as N-95 masks to institutions across the U.S.
“We’re also seeing coming up on the horizon is actually shortage of gloves, which is kind of scary because we can reuse N-95s, but we cannot reuse gloves,” she said, noting that there is no cleaning protocol for gloves to sterilize them for reuse.
“It’s amazing that almost a year into this, we just haven’t solved the PPE crisis,” she added.
Vin Gupta, MD, affiliate assistant professor of health metrics sciences at the Institute for Health Metrics and Evaluation at the University of Washington, said that requests for clinician volunteers in areas with high needs have been successful so far.
For instance, he said that the Society of Critical Care Medicine sought volunteers for Indian Health Services in South Dakota, which had difficulty meeting the need for staffed ICU and ER beds, and was met with overwhelming response.
He noted that all branches of the military have critical care transport teams in place that consist of ICU physicians, nurses and respiratory therapists to be deployed to respond to potential pandemics, “but this has not been utilized nearly to the extent that we thought it would be.”
He also said that officials in El Paso, Texas, recently requested support from a local airbase to aid in the COVID-19 response among hospitals in the area, but this, along with civilian efforts in South Dakota, feel like “bandage” approaches.
New York and other states, he said, have made moves to lower regulations on licensing to allow trained professionals to provide care across states without the need for excessive paperwork, and “it feels like that should be in place for all 50 states right now until the end of the pandemic.”
Gupta added that federalized efforts are needed to create a more unified response both from military teams and civilians to address COVID-19 care.
Moving forward, Malsin said that universal messaging and consistent guidelines on COVID-19 — preventive measures, treatment and eventually vaccination — is needed to aid physician response to the pandemic.
For instance, she said that while remdesivir was the first treatment approved for COVID-19 by the FDA, WHO recommended against its use. However, the Infectious Diseases Society of America said it will continue to recommend remdesivir for patients with severe COVID-19.
“What are the guidelines at this point?” she asked.
She added that similarly, once vaccines are approved, universal messaging is needed on how people should be vaccinated, who needs to be vaccinated and how to convince those who are vaccine hesitant to get the vaccine.
“An organized, clear message is what we need at this point,” Malsin said.