By Rose Hoban
As the number of COVID-19 cases climbs in North Carolina, hospitals across the state are feeling the strain of an influx of patients sickened by the lingering coronavirus.
Daily case counts topped 3,000 several times over the past week. Along with those growing cases, the number of people filling hospital beds with COVID-19 generated disease has also ticked up to more than 1,500 patients as of Tuesday, with 370 COVID-19 patients in ICUs statewide.
One recent development has been that many patients from rural areas are landing in beds in smaller hospitals, particularly in the northwestern part of the state, where more than a quarter of the state’s patients – and close to a third of the state’s ICU patients – currently are hospitalized.
“Over the past four weeks or so we’ve seen a significant uptick in our community, in our county and certainly in our hospital,” said Joseph Mazzola, a physician leader at the Statesville-based Iredell Health System, which falls in the Triad Healthcare Preparedness Coalition area.
Though the sheer volume of patients has tested the mettle of health care workers, lessons learned in ICUs across the state and country over the past eight months of treating illness related to COVID-19 offer glimmers of hope in this notably dark time.
These lessons might even change how intensive care is provided beyond the pandemic, including ways to avoid the use of mechanical breathing machines which can often bring as many problems as they solve.
Breath of life
In the spring, news headlines screamed about a looming shortage of mechanical breathing machines, known as ventilators. Prior experiences with influenza epidemics had led medical planners to worry that patients suffering from a novel virus causing respiratory disease would require ventilators to keep patients alive. Early guidance from European doctors suggested that was the case, as physicians in northern Italy had to contemplate rationing ventilators to only those projected to survive.
But over the past few decades physician-researchers treating patients with Adult Respiratory Distress Syndrome (ARDS), a frequently fatal condition where ICU patients’ lungs fail catastrophically, had found some alternatives to using ventilators.
“Physicians have become more comfortable with patients with more severe hypoxemic respiratory failure,” said Shannon Carson, head of pulmonary medicine at UNC Hospital in Chapel Hill.
“We saw pretty early that these patients had a difficult time on mechanical ventilator when they required it,” he said. “Some of them could avoid mechanical ventilation with extra time of intermediate levels of support.”
Some of that support uses high flow oxygen delivered through a nasal cannula, a tube secured just below a patients’ nose that blows air into the upper airway. Or patients can get oxygen delivered through facemasks with high volume and/or forced air.
Changing positions
Something else ICU physicians have practiced more is to lay patients receiving oxygen face down on their stomachs, a technique known as proning, for as much as 16 hours a day. ARDS researchers had found that patients who were proned had fewer lung injuries and better distribution of oxygen throughout their lungs, something that’s extended to COVID-19 patients.
“The proning protocols came from typical ARDS, for example,” Carson said. “Use of high-flow nasal cannula oxygen, all that literature, is from non-COVID patients.”
Researcher and physician Amesh Adalja, from the Johns Hopkins Bloomberg School of Public Health, said some of these ventilation techniques were on the cusp of wider use, but COVID pushed practitioners over that edge.
“I think we always talked about prone position ventilation, but almost as a thing for refractory cases, we never had people that are just sitting there, on nasal cannula laying on their belly,” Adalja told a group of reporters in a recent conference call. “That probably will be something we’ll do more.”
Carson said there are other benefits to not intubating patients if that’s possible. It spares people the effects of sedative drugs typically used with ventilators.
“Some of the neurologic effects of this viral infection, [patients] were very difficult to keep sedated, which is necessary when you have severe lung injury, because you don’t have any oxygen reserve to be agitated and moving around,” he said. “It took high levels of sedatives to manage them safely. And that then leads to long periods of time of waking up and being able to participate in the type of care required, eventually get them off the mechanical ventilator.”
“We developed a sense that it was much better to avoid intubation when possible, so we can avoid deep sedation,” he said.
These changes, along with new medications, mean the COVID-19 death rate is starting to fall. A study published in the late summer in the Journal of Hospital Medicine found that mortality was starting to tick down among all age groups. And a study published in early November found that the death rate from COVID has dropped by about 30 percent since the beginning of the pandemic.
Separating infectious patients
One of the techniques that is now almost universally practiced among hospitals is to separate patients who have COVID from those who do not. In the past, a ward in a hospital might have a handful of patients with an infectious disease, alongside those with other problems. That was back in the day when there wasn’t such an overwhelming demand for personal protective equipment. Health care personnel were able to put on and take off the PPE for patient care. But with shortages of PPE, that comparatively wasteful technique was quickly abandoned.
Instead, hospitals clustered all their COVID patients, either in the far end of the hallway or on a different floor. This has allowed for medical workers to conserve their PPE.
“Once you put on your protective gear, you stay in it as you move throughout the unit,” said Jeffrey McClung, an internist from Cone Health in Greensboro. He also said that means the staff only needs to take off, or doff, their gear only once as well.
“You know, the doffing is actually when you have the highest risk of exposing yourself. And by minimizing the number of times you have to doff, it really improves the safety for the staff as well.”
As COVID spread across the state, Cone Health’s old Women’s Hospital had just closed in late February as the system opened a new Women’s & Children’s Center. Only weeks later, patients sick with COVID-19 started filling up beds at Cone, generating difficulties with segregating those infected with the novel coronavirus from others.
Standing empty, the facility a few blocks away beckoned. Now that building has been dubbed the Green Valley COVID unit and will serve the system for treating patients until the pandemic wanes.
“It was honestly a stroke of great luck for us,” said McClung, who became the medical director of the Green Valley unit. “One of the big benefits of having this facility … is it allows us to focus all of these patients in one location.”
Not every hospital system has an empty facility sitting around waiting for infectious patients, but even smaller facilities have been able to make adjustments. At the Statesville-based Iredell Health System, the engineering team created additional negative pressure rooms where the airflow does not return to the main building but ventilates to the outside.
“We have clustered those together so that exactly like you’re hearing from other organizations, we’re trying to keep our COVID positive patients in cohorts near each other,” said Iredell Health’s Mazzola. “That’s a benefit, one, for the patient but also an infection control process that I would imagine most hospitals are attempting to do.”
Iredell Memorial Hospital, the flagship facility, also has an entire floor with negative pressure rooms, giving the hospital additional capacity others may lack.
“It was a decision to be made that they could do it because they were making the addition to the hospital at the time and it was just something they did. So it makes us a little unique because most hospitals don’t have that many negative pressure rooms,” Mazzola said.
More teamwork
While not a lot of the techniques will change and some smaller hospitals won’t have the space to segregate infectious patients, Carson said he hopes for one wide-scale change post-COVID in research.
“If there’s any change that has happened that should continue going forward, it has been these large, rapid, start-up platform clinical trials, like the ones that informed the use of dexamethasone and discouraged the use of hydroxychloroquine,” Carson said.
Those two bodies of research, for example, were accomplished quickly because many medical centers banded together, wrote and followed common protocols, pooled their data and made the research transparent. Instead of competing, the researchers cooperated, allowing practitioners to amass a large enough sample of patients receiving a given treatment, monitor their outcomes and come to conclusions in record time.
“What I really want to see is that these rapid startup clinical trials with multiple centers contributing data will continue with support of the National Institutes of Health and international critical care societies,” Carson said.
On a more micro level, Mazzola said his intensive care crew has been using a collaborative model to deliver care.
“We really emphasize team rounding, where different specialties and clinicians will go into the room, they’ll put on all their personal protective equipment, they’ll go see a patient together to coordinate care,” he said. “That decreases the risk of exposure to our clinicians, or doctors or nurses or therapists. And also it protects the patient from having a lot of extraneous people in the room.”
He said once the pandemic is in the rearview mirror, this model should remain.
Another thing that will likely remain once the pandemic subsides is the increased use of telemedicine.
“I also think the utilization of tele-visits or telemedicine or bringing the family and having discussions using some sort of iPad technology or virtual technology will be something that will stick long into the future,” Mazzola said. “Those are things we’ve talked about, probably for the past 15 years in medicine, but have been slow to adopt.
“This pandemic has forced us into incorporating them quickly. And so I think we’ll see those things stick in the coordination of care.”
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