With no clear guidelines on how to treat its first coronavirus patients, the ICU used teamwork to find its way through.
June 22, 2020 - By Tracie White
The first coronavirus patients to arrive in the intensive care unit at Stanford Hospital were wheeled in on gurneys, sometimes struggling for breath, often with frighteningly low levels of oxygen circulating in their blood. They were pale and scared. No family members were allowed to be present, and it was up to the ICU team to make life-or-death decisions fast.
This was early March, just about the time the World Health Organization designated the coronavirus outbreak a pandemic, and no one knew for sure how best to treat patients with this extremely infectious disease. No one on the ICU had even seen it before. There was little reliable research and no standardized treatment guidelines. Mostly, there were just rampant rumors of high mortality rates and even higher levels of contagion. The ICU team had to start from scratch.
“It was nerve-wracking,” said Dwayne Free, one of the frontline respiratory therapists, whose job was to care for these patients at their bedside. “There were so many questions around how the virus was spread. People were scared. Were there going to be enough ventilators? Enough personal protective equipment?” It was clear from the beginning that, like the rest of the hospital during this emergency, the ICU couldn’t just follow standard procedures, so early on they formed a team to set new guidelines as the numbers of patients slowly increased.
“We all agreed we needed to have sets of guidelines on how we would treat patients based in the beginning on evidence from China,” said Norman Rizk, MD, senior associate dean of clinical affairs at the School of Medicine and medical director of Stanford Health Care’s ICU. “We also needed to create room for a potential surge,” added Rizk, the Berthold and Belle N. Guggenhime Professor.
Led by Angela Rogers, MD, a pulmonary critical care specialist at Stanford Health Care, a group of experts inside and outside the ICU formed a COVID-19 critical care task force and started meeting weekly — later three times a week — at 7 a.m. to hash out best-practices guidelines. At its peak during those early months, the ICU was treating 10 to 15 patients at a time, and the staff continued to prepare for a potential surge.
“Right away we knew we had to work together as a team,” Rogers said. “It quickly became evident that aspects of COVID-19 care were really different than anything we’d seen before. All voices needed to be heard. The respiratory therapists, nurses and pharmacists were crucial to the task force. They knew what could and couldn’t be done and what was safe to try.”
This multidisciplinary team of roughly 50 health care workers including physicians from a variety of specialties (ICU anesthesia, emergency care, pulmonary neuro-critical care, infectious disease, hematology and palliative care), nurses, respiratory therapists, experts in ethics and a pulmonologist from ValleyCare hospital — shared what bits of information they could gather. Some called colleagues in New York or Italy, where hospitals were dealing with a surge of COVID-19 patients, for advice. They debated reams of research gathered through after-hours internet searches. They listened to each other, shared their ICU experiences and tried to learn from the patients.
“We knew that things had the potential to escalate into a surge,” said Javier Lorenzo, MD, clinical assistant professor of anesthesia. “We quickly realized we needed a body that could field questions and make policies. We wanted a way to add some scientific rigor to the decision-making process.”
Similarities with acute respiratory distress syndrome
While a lot was unknown about COVID-19, scientists knew it was caused by SARS-CoV-2, or severe acute respiratory syndrome coronavirus 2. They knew the virus attacked the lungs, causing inflammation and infection, and reducing oxygen to the rest of the body. But there was a lot that remained unclear.
“What we did know was this was very similar to another condition called ARDS — acute respiratory distress syndrome — something that has been studied for 50 years,” said Rogers, who is also an assistant professor of medicine. ARDS causes fluid to collect in the lungs’ air sacs, depriving the body of oxygen. It, too, can be fatal, and the standard of care includes the use of ventilators. Despite years of research, though, there remains no approved drug to treat the disease, Rogers said.
“With ARDS, we often intubate and use ventilation to protect the lungs and allow them to heal,” she said. “We knew it was important to keep the lungs safe.”
While there appeared to be many similarities, there were also clear differences between the two conditions. Those differences were debated during team meetings. Thousands of unvetted research studies were flooding the internet, making treatment decisions all the more difficult. Questions constantly arose. Should they be using experimental drugs, like remdesivir, or drugs approved for other uses, such as hydroxychloroquine, which is prescribed for malaria and lupus? If COVID-19 was an inflammatory disease, what about using drugs to boost the immune system? Since blood clots were becoming a serious concern, should anticoagulation medication be considered? There were no clear-cut answers.
“Among physicians, there is always a strong desire to do something rather than nothing,” Rogers said, especially when faced with a patient who may be dying. Still, the best treatment option is often to do less rather than more, she said. The goal became to wait for clear evidence, whenever possible, before changing practices.
“First, you do no harm,” she said. “As we start reaching for therapies, we had to remember these patients are really fragile.”
Few COVID-19 patients hospitalized
Only a small percentage of coronavirus patients ever see the inside of an ICU. Most are treated and sent home to mend. Yet those who are hospitalized tend to need round-the-clock care. Usually, clinicians place them on supplemental oxygen, which is supplied through a face mask or a tube inserted into the nose. If the patient continues to deteriorate, they consider a ventilator. This involves inserting a breathing tube through the patient’s mouth and into the airway, then attaching the tube to the mechanical ventilator.
“Part of the problem was that these patients didn’t look as bad as they should with the extremely low oxygen levels they were showing,” Lorenzo said, making it hard to know when a more invasive procedure was needed. “We are still learning how the virus affects the lungs, just how diffuse the inflammation is and how it affects the transfer of oxygen. It really just creeps up on people.”
“We were all worried about the risk of aerosolizing infectious particles,” Lorenzo said, explaining how if the ventilation tubes aren’t secured properly, air from the patient’s lungs can spew across the ICU room. But best practices early on appeared to be to ventilate earlier rather than later. The risk of death appeared too high without ventilation. So the team came up with a plan for how to conduct the procedure with as little risk of infection as possible, Lorenzo said. An airway team of a dozen or so clinicians was made available 24/7 to perform the procedure whenever necessary. The goal was to keep the number of workers in the ICU to a minimum, which usually meant only an anesthesiologist, respiratory therapist and registered nurse. Those three would get in and out of the room as quickly as possible, while still providing the best care.
“The physicians wrote the orders to guide us and to make sure everyone is safe, but in the end we had to go in the room,” said Free, the respiratory therapist. “I was worried at first about whether I was doing everything right — if I’d followed the video on how to don and doff the personal protective equipment correctly. Or if anyone else even knew how to make sure I did.”
Once in the room, Free, joined by a nurse and physician, would assist the doctor in inserting the breathing tube while suctioning out secretions, then attach it to the ventilator, making sure the patient was comfortable and all the connections were tight enough to prevent air leaks. The respiratory therapists also occasionally assisted with tracheotomies for those patients who were still deteriorating on breathing tubes, making an incision in the neck to insert the tube directly into the windpipe.
“The hardest part for us was at the bedside,” Free said. “You go in and see these patients in their most vulnerable state, really struggling to breathe, but right next door the same situation is happening. You try to keep them as comfortable and safe as possible. Then you have to just do your job, move on. I’d go home at night and talk about it with my wife. She’s a critical care nurse and could understand.”
As weeks passed, the team learned that they could defer intubating some patients by providing oxygen via other means. They also found that patients could, in fact, stay on ventilators for weeks, even months, and still recover. Following the standard procedures designed for ARDS patients seemed to work well. As quickly as they could, the ICU team developed its own best practices guidelines.
During those first months, they carefully recorded what they learned in a document now available online. It has been used as an information source by other Bay Area hospitals. And while it will continue to change, the team hopes what they’ve learned can add to the global knowledge base about the new virus.
“We are still learning,” Rogers said. “We’ve seen enough patients to learn a lot from them, but there’s no way to say these will always be the best treatments. Thankfully, we now know three months later that most people who get COVID will get well. Even those intubated for weeks and weeks we saw walk out of the hospital. It was amazing.”
Stanford never saw the surge it planned for; perhaps early stay-at-home orders in the San Francisco Bay Area helped reduce infections. Maybe the fact that the Bay Area is not as densely populated as places like New York helped. At its peak, the ICU cared for about 25 patients, far fewer than the 80 planned for. That helped keep enough supplies of protective equipment on hand to ensure frontline workers were safe from the virus. So far, survival rates of COVID-19 patients in the ICU remain high, at 80%. But the future is far from clear.
“Not having family members at the bedside is really hard,” Lorenzo said. “That element of having a loved one next to you, a friendly voice — it’s really missed. We do communicate with families over tablets. I call my coronavirus families every day to give them the best update I can. Some patients get better, but some don’t. I do my best to advocate for them. ”
As the number of COVID-19 patients in the ICU has decreased, the team is now back to meeting just once a week. They continue to share what they learn as new studies are published, and some conduct their own clinical trials.
“We learn from our mistakes,” Lorenzo said. “We refine our practices, try to make them a little bit more efficient. We rest. We take care of ourselves and our loved ones. We realize now that this is probably not going to be a peak, but a trickle of patients for a long time to come.”
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