Emergency Department Management and Outcomes of COVID-19 Acute Hypoxemic Respiratory Failure During the New York City Surge

Study Objectives: Delays in intensive care unit (ICU) admission for critically ill patients are associated with worse outcomes, but the effect of “boarding” during the COVID-19 pandemic has not been well characterized. This study describes the emergency department (ED)-based care for patients presenting with COVID-19-related acute hypoxemic respiratory failure (AHRF) to five hospitals in a large, academic health system during the initial surge in New York City, examining both respiratory modality choice and settings. For those managed with noninvasive respiratory support, we also aimed to explore the association between ED boarding time and patient morbidity and mortality. Methods: We conducted a retrospective cohort study of ED patients presenting from 3/1/2020 to 7/10/2020 with COVID-19-related AHRF and requiring ICU admission at any time during their hospitalization. Patient demographics, comorbidities, severity of illness (Mortality Probability Model III on admission), clinical course, including the use, settings (initial and changes), and duration of respiratory support modalities (ie, noninvasive ventilation [NIV], high flow nasal cannula [HFNC], invasive mechanical ventilation [IMV]), as well as hospital site, were collected through validated electronic query and standardized manual chart abstraction. AHRF severity was defined using a PaO2/FiO2 ratio (PF): 200-300 (mild), 100-199 (moderate), and <100 (severe). For patients without a PaO2, the PF was imputed using SpO2/FiO2 ratio using previously validated non-linear conversion. Boarding was defined as the time interval from ED request for admission to ED departure. The primary outcome was a composite outcome of ICU admission, intubation, or mortality within 48 hours of ED arrival. Descriptive analyses stratified by boarding duration and AHRF were completed. Multivariable logistic regression modelling was used to determine the association between ED boarding and the primary outcome. Results: A total of 679 ED patients with COVID-19 AHRF required ICU admission during the study period. They were managed with low flow oxygen only (261, 38.4%), or with NIV (120, 17.7%), HF (51, 7.5%), and/or IMV (99, 14.6%), with setting ranges detailed in Table 1. Of the patients with a known PF ratio (N=418), 110 (26.35%) had mild, 34 (5.0%) had moderate, and 274 (40.4%) had severe AHRF. Of these patients, 279 (41.1%) had a change documented to their settings, with increased likelihood of adjustments with longer boarding time (p<0.001) and higher AHRF severity (p<0.001). Median boarding duration across all site was 9.5 hours (IQR 5.3-16.9 hours) with site variation. AHRF severity and support modality were not associated with differences of boarding time (p = 0.77 and p=0.54). Controlling for age, sex, race, and severity of illness, boarding time was not associated with worse patient outcomes in 48 hours (OR 0.85, 95% CI 0.67-1.08, p=0.17) Conclusion: During the COVID-19 pandemic, critically ill patients presented to the ED and boarded for long periods of time, requiring prolonged ventilatory management. Despite the surge state and resource limitations, boarding times did not worsen post-ED outcomes for patients managed with non-invasive modalities. [Formula presented]

External Validation of the Quick COVID-19 Severity Index: A Prognostic Tool for Early Clinical Decompensation

Study Objective: To externally validate a risk-stratification tool—the Quick COVID-19 Severity Index (qCSI)—developed by Haimovich et al. to predict 24-hour respiratory decompensation in admitted patients with COVID-19. Methods: This was a retrospective observational cohort study of COVID-19 patients admitted from the emergency department between Feb 29, 2020 to Feb 1, 2021. The health care system is composed of a mix of 2 community and 4 academics EDs in a major metropolitan area. Patient demographics, vital signs, laboratory results were extracted from our institutional COVID-19 Data Warehouse. Following the convention of qCSI variables, respiratory rate (breaths/min), pulse oximetry (%), and oxygen flow rate (L/min) were used to calculate points between 0 to 12, with higher points associated with highly likelihood of respiratory decompensation within 24 hours. Results: 35,696 COVID-19 patients were admitted via the emergency department during the study period. The mean qCSI was 1.73 (SD 1.82) for non-ICU admissions (n=34,647). The mean qCSI was 2.83 (SD 2.53) for ICU admission (n=1,049). As of the time of submission, ED treat and release patients, as well as decompensation results are pending. Conclusions: In this validation study of qCSI using a large system cohort of COVID-19 patients, qCSI appears to correlate strongly with clinical triage for admission decision to regular floor vs. ICU level care. Further analysis is needed to identify 24-hour respiratory decompensation after regular floor admission.

A novel protocol for the management of diabetic ketoacidosis in COVID-19-infected patients

INTRODUCTION: In early March 2020, COVID-19 spread in New York City. This paper shows trends of rising cases of DKA associated with a worsening COVID-19 pandemic in New York City. With the potential for such a large number of DKA patients, our institution found a need for revised glycemic management protocol. We discuss how a multidisciplinary team designed a protocol to care for patients with COVID-19 infection and DKA. METHODS: Five of The Mount Sinai Health System's EDs are on a shared electronic health record system (Epic Systems, Verona, WI). Deidentified visit data extracted for routine quality review was made available for analysis. We looked at total visits and select visit diagnoses related to DKA through March, April and May 2019 and compared those counts to the same period in 2020. Our protocol was developed by stakeholders in a multidisciplinary hospital team. We focused on the basic tenets of DKA management: insulin therapy, fluid resuscitation, and electrolyte repletion. RESULTS: A total of 93,218 visits were recorded across the five EDs from March 1-May 31, 2019. During that period there were 106 diagnoses of DKA made in the EDs (0.114% of visits). Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0.363% of visits). This coincides with the height of the Sars-CoV-2 pandemic in New York City. To address this surge, our protocol decreased the frequency of fingerstick monitoring, with changes to insulin dosing allowing admission to non-ICU beds. We transitioned from a provider-driven protocol to a nurse-driven protocol to avoid treatment delays due to order placement. Insulin infusion rate charts were created to provide nurses guidance on dosing modifications. To minimize ARDS risk, our protocol's fluid replacement recommendations lowered resuscitation and replacement rate volumes, adjusting based on provider reassessment. Lab values were monitored every 3-4 hours. CONCLUSIONS: There is a correlation between the rise of the Sars-CoV-2 pandemic in New York City and a net rise in patients diagnosed with diabetic ketoacidosis. We believe our DKA protocol will facilitate safe and effective management of patients with COVID-19 and DKA, reducing the healthcare burden associated with protocols that necessitate frequent treatment modifications and ICU-level care.

Mount sinai hospital institute for critical care medicine COVID-19 pandemic policies and procedures

INTRODUCTION: COVID-19 2020 pandemic with New York City (NYC) as the epicenter necessitated an unprecedented increase in critical care capacity and development of institutional guidelines for care. We describe our drastic increased ICU capacity and how we created and disseminated our guidelines. We hope our experiences help others manage their COVID-19 peaks. METHODS: Mount Sinai Hospital System includes a medical school and eight campuses, the largest being Mount Sinai Hospital (MSH). Since 2013, MSH had system-wide staffing models, cross credentialed staff, and combined leadership. MSH has and Institute for Critical Care Medicine (ICCM) that includes seven adult ICUs, 45 critical care faculty, rapid response team (RRT), vascular access team (VAS), difficult airway team (DART), patient safety quality team (PSQ), clinical research team, and post-ICU recovery clinic. ICCM coordinated COVID-19 critical care response within MSHS. ICCM, Emergency Medicine, Anesthesiology, and Infection Prevention helped develop systemwide guidelines on our COVID-19 website accessible to all hospital employees. RESULTS: MSH expanded from 1139-beds, 104 ICU beds, to 1453 beds, 235 ICU beds during the COVID-19 peak. CONCLUSIONS: MSH's response to COVID-19 surge by expanding critical care bed capacity from 104 to over 200 ICU beds required teamwork across disciplines. We developed new guidelines for airway management, cardiac arrest, anticoagulation, vascular access, and proning that helped streamline workflow and accommodate the surge in critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units by leveraging a tiered staffing model. This approach to rapidly expanding bed availability and staffing across the system was made possible by the collaboration between ICCM, emergency department, anesthesia department, and infection prevention, and helped to provide the best care for our patients and saved lives.

Rapid deployment of an ED-ICU for the COVID-19 pandemic

INTRODUCTION: The COVID-19 pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume. This paper describes one institution's Emergency Department innovation at the center of the COVID crisis, including the creation of a temporary ED-ICU and development of interdisciplinary COVID-specific care delivery models to care for critically ill patients. METHODS: Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently resourced due to its size and lack of negative pressure (NP) rooms. The ED-based Observation Unit, which has four NP rooms, was deemed to be the ideal spot for a new ED-ICU. An interdisciplinary and intradepartmental task force was critical to this development. This task force worked to ensure the physical supplies, medications, staffing, and clinical protocols were appropriate to allow for the proper functioning of the ED-ICU. RESULTS: Within one week, the ED-based Observation Unit was quickly converted into a COVID-specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit. The ED-ICU had all the functional and staffing capacities of an ICU, and was able to efficiently care for large numbers of critically ill patients. All critically ill patients in the ED were treated in the ED-ICU. Further, all intubations and non-invasive ventilation were able to occur in the negative pressure rooms. CONCLUSIONS: The Mount Sinai Hospital Emergency Department rapidly adapted the delivery of care and treatment models to meet the challenges of the COVID-19 pandemic. An ED-ICU was rapidly built by converting the prior observation area (a 27-bed zone). A redesign of a new space in a large U.S. academic hospital often requires months, if not years, of planning and negotiations with the varying hospital interests involved. With the pressure of high COVID demand, this conversion was executed in approximately 1 week, from the initial decision to full activation. Moreover, the unit functioned during the peak of the NYC COVID-19 epidemic largely as envisioned and required surprisingly few space or workflow modifications mid-course. Its success was due to the hard work of the leadership team and front-line providers and the collaboration across the institution.

TRACHEOSTOMY TIMING AND OUTCOMES IN PATIENTS WITH COVID-19 PNEUMONIA

SESSION TITLE: Lessons from the ICU: What have We Learned about the Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Benefits of early tracheostomy (2-10 days after intubation) include decreased sedation, days on ventilator, ICU length of stay and long-term mortality. In addition, it helps improve patient’s comfort level, tracheal suctioning, oral hygiene and facilitates early mobility in comparison to delayed tracheostomy (7-14 days after intubation). With the recent COVID-19 pandemic, an unprecedented surge in patients requiring prolonged mechanical ventilation led to an increase in the need for tracheostomies. Tracheostomy is an aerosol-generating procedure that raises potential risk to the proceduralists. Therefore, international professional otolaryngology and surgical organizations published guidelines, which recommended delaying tracheostomy to after 21 intubation days in order to ensure viral clearance prior to the procedure. In the setting of these well-intended practice guidelines, intensivists are faced with a new dilemma;following the standard of care for tracheostomy planning vs. delaying the procedure without evidence to support the new recommended guidelines. METHODS: We utilized our previously established Institute for Critical Care Medicine Tracheostomy Team (ICCM-TT), with its multidisciplinary departments, which include Critical Care, General Surgery, Cardiac and Thoracic Surgery and Otolaryngology. In April 2020, throughout the nine ICUs dedicated to the management of COVID-19 patients, the ICCM-TT performed 111 tracheostomy procedures. Case selection involved a multidisciplinary team evaluation of patient’s clinical status and wishes after goals of care discussion. Median time from translaryngeal intubation to tracheostomy was 11 days. All cases were performed at bedside, using percutaneous dilatational technique with bronchoscopic guidance. Additionally, real-time ultrasound guidance was utilized in cases identified to have difficult anatomical landmarks. All of the 111 procedures were performed within 1 day of the tracheostomy request, unless medical instability deferred the procedure or revisiting goals of care was needed. RESULTS: Of the patients who received tracheostomy for COVID-19 prolonged respiratory failure: 35 (31.5 %) patients discharged home alive, 23 (20.7 %) weaned from mechanical ventilation (no ventilator support, downsized or decannulated) but remain hospitalized on non-ICU floors, 33 (29.7 %) expired and the remaining 20 (18 %) are either in the ICUs or undergoing active weaning in a designated weaning unit. Of note, none of the ICCM-TT proceduralists acquired COVID-19 infection, all have been tested negative for antibodies. This may be due to the thorough pre-procedural planning, adherence to ICCM-TT protocols and vigilance in maintaining infection control guidelines. CONCLUSIONS: Developing a dedicated tracheostomy team and following standard of care in timing of tracheostomy for COVID-19 patients avoided unnecessary delay of patient’s care without risk of viral transmission to the staff. This facilitated patient’s ventilator weaning and discharges, which improved ICU throughput. CLINICAL IMPLICATIONS: Our results support creating a dedicated tracheostomy team and following standard of care without the need to delay a necessary procedure for COVID-19 pneumonia patients. Furthermore, this deemed safe when infection control protocols were strictly followed. DISCLOSURES: No relevant relationships by Adel Bassily-Marcus, source=Web Response No relevant relationships by Ella Illuzzi, source=Web Response No relevant relationships by Roopa Kohli-Seth, source=Web Response No relevant relationships by Evan Leibner, source=Web Response No relevant relationships by Ahmed Mohammed, source=Web Response