With the latest and most powerful surge of novel coronavirus infections well underway, health care workers in hospitals across the nation have continued to face daunting battles with the debilitating and deadly effects of COVID-19.
The shadow of the disease has lengthened as we’ve officially entered winter. Now, as we approach New Year’s Day, the daily number of COVID-19 cases in the United States continues to surge close to 200,000, and the daily death toll surpassed 3,000 more than once on dark days this month. The assault has strained hospital resources, from personal protective equipment to available hospital beds to the professionals dedicated to caring for the sick.
Yet the fight against COVID-19 has not been one-sided. From a standing start last January, when the health care system encountered the virus for the first time, hospitals have made steady progress in treating patients infected with SARS-CoV-2, the virus that causes the disease. In general, as providers across the country learned more about treating COVID-19, they lowered death rates, shortened hospital stays, and lessened their use of mechanical ventilation, which carries significant risks. Close to home, these and other COVID-19 care improvements were reflected in a September report from the Colorado Hospital Association.
The 12 hospitals comprising the UCHealth system, which contributed data to the CHA report, tell a similar story. A November 19 town hall presentation revealed details in a statistical contrast between the periods from March 1 to May 30 and September 1 to November 13 at UCHealth.
- Overall COVID-19 mortality fell from 12.3% to 5.9%.
- Overall length of hospital stay fell from 11.0 days to 5.9 days.
- The percentage of patients requiring an ICU stay fell from 33% to 23%.
A multi-front response to COVID-19
The benefactors of this progress were people with COVID-19 who battled through the disease with the help of thousands of committed health care professionals and staff. As of late December, about 5,000 individuals with COVID-19 who received treatment at UCHealth hospitals recovered. (Watch this video to see how a sense of teamwork among UCHealth care givers has never been stronger.)
No single factor explains the progress. Providers continue to rely on a limited number of medical treatment options, improved techniques to keep patients oxygenated, remote monitoring of patients to keep them out of the hospital safely, and standardized, evidence-based care that leads to the best outcomes in a variety of settings.
Indeed, the biggest driver of success has been experience gained in treating a mysterious foe, said Dr. Jean Kutner, chief medical officer at UCHealth University of Colorado Hospital on the Anschutz Medical Campus.
“We have to remember that this was a brand-new disease,” Kutner said. “When we first started treating it in March and April, we didn’t know a lot. Nobody had any experience with it. Since then, the science and evidence have improved.”
Medications improve care options for COVID-19
Providers today have more medications at their disposal than they had at the outset of the pandemic. They have been used to treat people who need oxygen therapy because of their illness, as well as those with mild to moderate symptoms, Kutner noted. The drugs include the anti-viral remdesivir, the corticosteroid dexamethasone, and the monoclonal antibody bamlanivimab, recently approved by the FDA for emergency use.
Early in the pandemic, UCHealth also began treating some COVID-19 patients with convalescent plasma. This plasma, donated by recovered COVID-19 patients, contains antibodies that may help the immune systems of other patients with the disease fight their infections.
Early patient surges also revealed that COVID-19 caused dangerous blood clots. The response: aggressive treatment with anticoagulant medications like Lovenox that prevent clots from forming, noted Dr. David Steinbruner, chief medical officer at UCHealth Memorial Hospital. University of Colorado Hospital also is part of a multicenter trial studying the use of tPA (tissue plasminogen activator) to treat blood clots that clog the lungs of COVID-19 patients with ARDS (acute respiratory distress syndrome).
The battery of medications offers providers options for patients in medical/surgical and intensive care units, but it will take time to figure out with certainty how effective they are, Steinbruner cautioned.
“We won’t know that until we have time to do a post-analysis,” Steinbruner said.
Finding COVID-19 care improvements by doing
It’s difficult to do that in the midst of a pandemic that merely slowed in the late spring before roaring back with a regional summer surge and the current nationwide wave, Kutner agreed.
“In medicine, we’re used to doing multiple clinical trials before we change practice,” she said. “COVID has tossed that on its head and we’ve had to lean on functioning and practicing medicine in a setting of rapidly changing evidence.”
Practice at UCHealth has changed in important ways as thousands of COVID-19 patients have come through hospital doors. The steady work has helped hospitals develop practices and policies that conserve resources to care for the sickest patients while delivering the best possible care for all, Steinbruner said.
“We’ve done a better job of teasing out who can avoid the hospital while also finding better ways to keep people off ventilators,” he said.
Socially distanced care
Kutner noted the importance of UCHealth’s burgeoning virtual health services, which allow providers to monitor oxygen levels, heart rate and other vital signs electronically, around the clock. The technology means less seriously ill patients can return home from emergency department visits or hospital stays with supplemental oxygen and remote monitoring devices. If danger signs like plunging oxygen levels occur, providers have an early warning.
“Virtual care has saved some people hospitalizations or gotten them into the hospital earlier in the course of their disease,” Kutner said. “We can then discharge them sooner, with oxygen, get them back home, and still feel that they are safe and being monitored appropriately. I think it has made a significant, positive difference.”
Finding breathing room
Early in the COVID-19 pandemic, hospital providers used mechanical ventilators aggressively to treat COVID-19 patients whose oxygen levels dropped precipitously. But prolonged ventilation can lead to a host of problems, from infections to delirium. Experience revealed that proceeding more cautiously with ventilation in COVID-19 patients could produce better results. For one thing, many of them could tolerate surprisingly low blood oxygen levels – as low as 85%, Steinbruner said. That contrasts with the greater than 90% oxygen levels intensive care units aim for in patients with pneumonia and other severe respiratory ailments.
“We figured out how to avoid invasive ventilations for those who don’t absolutely need it,” Steinbruner said.
The alternatives to mechanical ventilation include heated high-flow oxygen, oxygen facemasks, nasal tubes, and CPAP and BiPAP machines – all methods of delivering greater amounts of air to starved lungs without damaging delicate air sacs. Patients on supplemental oxygen also seem to benefit from moving from their backs to their stomachs, a technique called prone positioning long used in ICUs to help ventilated patients breathe better. The back-to-belly change improves oxygenation and helps some COVID-19 patients avoid intubation.
The adaptions to care did not occur in an orderly, predictable way. However, UCHealth worked to organize the lessons of COVID-19 care into “clinical pathways” for providers treating patients in the inpatient, outpatient, and emergency care settings, Kutner said. The pathways are available in the Epic electronic health record, where providers can easily consult them – and they can be updated in real time, as evidence warrants, Kutner said. The pathways are also available to providers outside the UCHealth system.
Frontline fight against the coronavirus
Of course, none of these improvements were or are possible without the dedication of providers and staff. Some 1,000 at UCHealth have offered to be redeployed from their regular assignments during the pandemic. Kutner said experienced clinicians and hospital medicine teams at UCH helped by creating support materials for people encountering COVID-19 care for the first time. Less experienced providers then supported those on the front lines by entering orders, talking with family members and other key tasks.
Redeployment is a challenging task that requires continuous planning, Steinbruner noted.
“We need clear lines of communication throughout our organizations on a regular basis,” he said. “If we need bedside nurses in acute care and the ICUs, what do we need to pull from and redeploy to locations within the hospital?” And all of the COVID-19 planning must take place in the environment of hospitals still dealing with traumas, heart attacks, strokes and other everyday critical problems, he added.
The challenges of COVID-19 continue for UCHealth and promise to toughen as the pandemic wears on and shows no signs of abating – even with the promise of widespread vaccinations drawing near. The wave of cases requiring hospitalization probably is not near cresting, which means hospitals must build up capacity for physical resources – ICU beds, IV tubing, heated oxygen delivery machines and the like – and for the providers and staff to administer care, Kutner said.
And both she and Steinbruner worry about the emotional toll the long battle is taking on those caring for patients.
“We are in the long campaign of this war and are asking how can we slog through while keeping people’s spirits up and making sure they can come back here every day and do it all over again,” Steinbruner said.
In the long run, hospitals can best defend their communities against the COVID-19 assault by sticking to the basics of clinical care and research, Kutner said.
“Treating COVID-19 is unpredictable,” she said. “That is one of the things that makes it difficult for us as providers and for patients. We have to trust the science and trust the evidence.”