Hospitals Retreat From Early Covid Treatment and Return to Basics
NOT FOR EXTERNAL DISTRIBUTION
SOURCE: Wall Street Journal
AUTHOR: Melanie Evans
Doctors are treating a new flood of critically ill coronavirus patients with treatments from before the pandemic, to keep more patients alive and send them home sooner.
Last spring, with less known about the disease, doctors often pre-emptively put patients on ventilators or gave powerful sedatives largely abandoned in recent years. The aim was to save the seriously ill and protect hospital staff from Covid-19.
Now hospital treatment for the most critically ill looks more like it did before the pandemic. Doctors hold off longer before placing patients on ventilators. Patients get less powerful sedatives, with doctors checking more frequently to see if they can halt the drugs entirely and dialing back how much air ventilators push into patients’ lungs with each breath.
“Let us go back to basics,” said Dr. Eduardo Oliveira, executive medical director for critical-care services for AdventHealth Central Florida, which recommends its doctors stick with pre-pandemic guidelines for ventilator use. “The less you deviate from it, the better.”
Advances also include new drugs, most notably steroids, for severely ill patients.
As the U.S. surge stretches into winter, hospital ICUs are seeing record numbers of Covid-19 cases. Even with more effective treatment, the high volume has required a record number of them on ventilators in the U.S. last week, according to Covid Tracking Project data.
Vaccines began distribution in the U.S. last week, but shots for most Americans remain months away. The disease has killed 1.68 million world-wide, according to Johns Hopkins University.
Last spring, doctors put patients on ventilators partly to limit contagion at a time when it was less clear how the virus spread, when protective masks and gowns were in short supply. Doctors could have employed other kinds of breathing support devices that don’t require risky sedation, but early reports suggested patients using them could spray dangerous amounts of virus into the air, said Theodore Iwashyna, a critical-care physician at University of Michigan and Department of Veterans Affairs hospitals in Ann Arbor, Mich.
At the time, he said, doctors and nurses feared the virus would spread through hospitals. “We were intubating sick patients very early. Not for the patients’ benefit, but in order to control the epidemic and to save other patients,” Dr. Iwashyna said “That felt awful.”
Ventilators can injure lungs by causing too much strain as the machines force in air. They deliver air and oxygen through a throat tube, which the body typically fights. “We’ve got gag reflexes that are pretty hard to go away, precisely to avoid things going into our lungs,” Dr. Iwashyna said.
As a safety precaution, doctors and hospitals limited the access of health-care workers to coronavirus patients on ventilators, giving them fewer opportunities to check on them. That meant patients required more powerful sedatives to keep them from pulling out throat tubes. Sedation increases risk for delirium, research suggests, and delirium increases the likelihood of long-term confusion and death.
Subsequent research found the alternative devices to ventilators, such as delivering oxygen through nasal tubes, weren’t as risky to caretakers as believed. Doctors also gained experience with Covid-19 patients, learning to spot signs of who might suddenly turn seriously ill, some said.
When the pandemic first overwhelmed hospitals in China and Italy, doctors questioned whether Covid-19 would require new treatment approaches. Better understanding of severely ill coronavirus patients in respiratory distress has increased confidence that they are similar enough to patients with other infections to rely on pre-pandemic guidelines for ventilators, according to doctors and hospitals.
Doctors at AdventHealth Central Florida use computers to select treatment options, and for Covid-19 patients, the system added options to calibrate ventilators using longstanding protocols, Dr. Oliveira said.
The computerized guides have helped spread the use of pre-pandemic treatment options, such as the amount of air to push into lungs per breath, across its 20 hospitals and emergency rooms, Dr. Oliveria said.
Nashville-based HCA Healthcare Inc., one of the largest hospital chains in the U.S., went a step further. Doctors get an alert from computers when patients aren’t getting the ventilator treatment that might benefit them. The company rolled out the alerts in June. Afterward, it compared treatment and outcomes for similar patients before and after the alerts. It found more doctors now follow the pre-pandemic protocols, which have reduced the number of deaths and shortened the time patients spend on ventilators, HCA’s chief medical officer said.
Overall, survival for Covid-19 patients increased 28% from April to September at HCA hospitals, though the company didn’t break out figures for ventilated patients. Doctors can use their judgment to ignore the alerts when other patient conditions make it medically necessary, the company said.
Researchers and doctors continue to study Covid-19 patients who require ventilators, and some experts have called for flexibility from pre-pandemic standards for doctors to decide how to calibrate ventilators. “It’s personalization, that’s the key word,” said John Marini, a professor of medicine at the University of Minnesota. “Guidelines are just guidelines.”
Before the pandemic, between about 30% to more than 40% of ventilator patients died, according to research. Numbers were sharply higher in the pandemic’s early hot spot in Wuhan, China. As the pandemic grew, hospitals in the U.S. reported death rates in some cases of about 50% for ventilated Covid-19 patients.
One study of three New York City hospitals found the death rate for all Covid-19 patients dropped to 7.6% from 25.6% between March and August after accounting for younger, healthier patients in the summer. Hospitals in New York were less crowded in August than during the April surge, which could increase mortality, the study’s authors wrote in October in the Journal of Hospital Medicine. The study also suggests patients may have benefited from new medications and improved treatment, they said.
Gains in treatment may diminish in a prolonged Covid-19 surge if doctors and nurses are overwhelmed and hospitals must keep out visitors, said E. Wesley Ely, a professor at the Vanderbilt School of Medicine, who studies the risks of intensive-care treatment, which include neurological damage and physical disability. Overextended doctors may again use heavy sedation if ICU teams can’t closely monitor ventilated patients, Dr. Ely said.
Notes on recovery
Less sedation combined with other measures also shortens hospital stays and improves survival, research shows. Among those measures: halting intravenous drugs for portions of each day to see if they are still needed, attempting daily to remove patients from ventilators and keeping patients moving. Contact with family also plays a significant role in recovery, research shows.
Christopher Thomas, a physician and assistant professor of clinical medicine and pulmonary and critical care with Louisiana State University Health, used heavy sedation on patients for a few weeks in the spring. It wasn’t his normal practice. “It felt like you were watching—being forced to watch—patients not get better,” Dr. Thomas said. He soon reverted to lighter sedation.
Baton Rouge General, where Dr. Thomas works, had also prohibited family visits to reduce contagion. In August, doctors decided it would be better to allow families to visit delirious patients to help with recovery, the usual practice before the pandemic.
“We tried iPads, FaceTime,” Dr. Thomas said, “but decided that in-person was essential for some patients.”
Deborah Walker couldn’t visit her husband, Ralph Walker Sr. , for weeks after he entered the Baton Rouge, La., hospital in mid-July. He was dizzy, nauseous and feverish. Doctors put him on a ventilator.
Ms. Walker, forbidden from visiting, spoke to and prayed for husband daily over an iPad. “Please come home,” she would say, and she promised him he could buy a guitar he wanted.
Mr. Walker already had 10 guitars hanging on the walls of the couple’s home in a Baton Rouge suburb. He also plays piano—they own two—and a drum kit is set up in the dining room. The night the couple met, Ralph sang to his future wife from the stage of a bar where he played.
Doctors halted Mr. Walker’s sedatives in early August, but he was largely unresponsive for about two weeks, Ms. Walker said. She first saw him open his eyes on Aug. 17. He said little for days. Doctors let two family members visit, hoping to rouse Mr. Walker.
His daughter arrived one day with a keyboard. Ms. Walker watched on an iPad in the hospital parking lot. “His fingers crawled up the keyboard, and he put them on the keys,” she said. Then he began to play, and she sang along.
“You could just see the light switch on,” Ms. Walker said.
Mr. Walker has since returned home. He continues to work with physical therapists to rebuild muscles to walk and regain enough strength in his wrist to play his new guitar.
Write to Melanie Evans at Melanie.Evans@wsj.com