ABSTRACT
Background: The novel COVID-19 pandemic created an unprecedented strain on healthcare systems, particularly on intensive care services. Balancing demand for intensive care unit beds with increased patient acuity challenged facility's abilities to provide access to care for patients with advanced liver disease. We report the development of unique practices designed to maintain clinical operations of our Medical Intensive Liver Unit (MILU). Methods: Consecutive patients admitted to the MILU at a United States quaternary care LT center between 08/27/2018 and 12/31/2020 were enrolled in a prospective registry and followed from admission to hospital discharge, LT or death. In March 2020, the MILU was geographically relocated to accommodate the COVID-19 pandemic surge and to protect the at-risk patients with liver disease. To facilitate this transition, new protocols were developed to rapidly train nursing and support staff and to adjust ICU throughput. Procedures were implemented to facilitate virtual models of clinical care and communication. Clinical working groups were assembled to re-design protocols encompassing acute liver failure, acute kidney injury, nutrition optimization, sepsis pathways, and perioperative management. Results: In 2020, 373 patients were admitted to the MILU, accounting for 408 hospital admissions and 472 MILU admissions. Of these patients, 124 patients (30.3%) died in-hospital. 279 patients (74.5%) were cirrhotic, and 26 patients (6.9%) were admitted for acute liver failure. The most common etiology of liver disease in patients with cirrhosis was alcohol-related liver disease (42.6%), increased from 2019 (33.3%). Average MELD-Na score was 30.1, increased from 2019 (27.2). 48 (12.9%) of these patients underwent LT in 2020, 35 (72.9%) of whom were transplanted during the same hospitalization as their MILU admission, and 22 (45.8%) directly from MILU. Conclusion: Data previously presented supports the MILU as a promising sub-specialty model for the improved intensive care of patients with advanced liver disease. The COVID-19 pandemic presented both logistical and clinical challenges for the delivery of care to this vulnerable patient population. Our experience mirrors national trends in increased severity of illness for hospitalized hepatology patients during the pandemic. Collaborative efforts in ensuring adherence to novel protocols and maintained communication within a multi-disciplinary team resulted in successful optimization strategies for bridging higher acuity patients to LT.