Surge capacity and capability of intensive care units across a large healthcare system: An operational blueprint for regional integration.

OBJECTIVE: Many hospitals were unprepared for the surge of patients associated with the spread of coronavirus disease 2019 (COVID-19) pandemic. We describe the processes to develop and implement a surge plan framework for resource allocation, staffing, and standardized management in response to the COVID-19 pandemic across a large integrated regional healthcare system. SETTING: A large academic medical center in the Cleveland metropolitan area, with a network of 10 regional hospitals throughout Northeastern Ohio with a daily capacity of more than 500 intensive care unit (ICU) beds. RESULTS: At the beginning of the pandemic, an equitable delivery of healthcare services across the healthcare system was developed. This distribution of resources was implemented with the potential needs and resources of the individual ICUs in mind, and epidemiologic predictions of virus transmissibility. We describe the processes to develop and implement a surge plan framework for resource allocation, staffing, and standardized management in response to the COVID-19 pandemic across a large integrated regional healthcare system. We also describe an additional level of surge capacity, which is available to well-integrated institutions called "extension of capacity." This refers to the ability to immediately have access to the beds and resources within a hospital system with minimal administrative burden. CONCLUSIONS: Large integrated hospital systems may have an advantage over individual hospitals because they can shift supplies among regional partners, which may lead to faster mobilization of resources, rather than depending on local and national governments. The pandemic response of our healthcare system highlights these benefits.

Inhaled corticosteroids do not adversely impact outcomes in COVID-19 positive patients with COPD: An analysis of Cleveland Clinic's COVID-19 registry.

Inhaled Corticosteroids (ICS) are commonly prescribed to patients with severe COPD and recurrent exacerbations. It is not known what impact ICS cause in terms of COVID-19 positivity or disease severity in COPD. This study examined 27,810 patients with COPD from the Cleveland Clinic COVID-19 registry between March 8th and September 16th, 2020. Electronic health records were used to determine diagnosis of COPD, ICS use, and clinical outcomes. Multivariate logistic regression was used to adjust for demographics, month of COVID-19 testing, and comorbidities known to be associated with increased risk for severe COVID-19 disease. Amongst the COPD patients who were tested for COVID-19, 44.1% of those taking an ICS-containing inhaler tested positive for COVID-19 versus 47.2% who tested negative for COVID-19 (p = 0.033). Of those who tested positive for COVID-19 (n = 1288), 371 (28.8%) required hospitalization. In-hospital outcomes were not significantly different when comparing ICS versus no ICS in terms of ICU admission (36.8% [74/201] vs 31.2% [53/170], p = 0.30), endotracheal intubation (21.9% [44/201] vs 16.5% [28/170], p = 0.24), or mortality (18.4% [37/201] vs 20.0% [34/170], p = 0.80). Multivariate logistic regression demonstrated no significant differences in hospitalization (adj OR 1.12, CI: 0.90-1.38), ICU admission (adj OR: 1.31, CI: 0.82-2.10), need for mechanical ventilation (adj OR 1.65, CI: 0.69-4.02), or mortality (OR: 0.80, CI: 0.43-1.49). In conclusion, ICS therapy did not increase COVID-19 related healthcare utilization or mortality outcome in patients with COPD followed at the Cleveland Clinic health system. These findings should encourage clinicians to continue ICS therapy for COPD patients during the COVID-19 pandemic.

Multiplex Ventilation: Solutions for Four Main Safety Problems.

BACKGROUND: The COVID-19 pandemic has led to an increased demand for mechanical ventilators and concerns of a ventilator shortage. Several groups have advocated for 1 ventilator to ventilate 2 or more patients in the event of such a shortage. However, differences in patient lung mechanics could make sharing a ventilator detrimental to both patients. Our previous study indicated failure to ventilate in 67% of simulations. The safety problems that must be solved include individual control of tidal volume (VT), individual measurement of VT, individualization of PEEP settings, and individual PEEP measurement. The purpose of this study was to evaluate potential solutions developed at our institution. METHODS: Two separate lung simulators were ventilated with a modified multiplex circuit using pressure control ventilation. Parameters of the lung models used for simulations (resistance and compliance) were evidence-based from published studies. Individual circuit-modification devices were first evaluated for accuracy. Devices were an adjustable flow diverter valve, a prototype dual volume display, a PEEP valve, and a disposable PEEP display. Then the full modified multiplex circuit was assessed by ventilating 6 pairs of simulated patients with different lung models and attempting to equalize ventilation. Ventilation was considered equalized when VT and end-expiratory lung volume were within 10% for each simulation. RESULTS: The adjustable flow diverter valve allowed volume adjustment to 1 patient without affecting the other. The average error of the dual volume display was -17%. The PEEP valves individualized PEEP, but the PEEP gauge error ranged from 17% to 41%. Using the multiplex circuit, ventilation was equalized regardless of differences in resistance or compliance, reversing the "failure modes" of our previous study. CONCLUSIONS: The results of this simulation-based study indicate that devices for individual control and display of VT and PEEP are effective in extending the usability and potential patient safety of multiplex ventilation.

Severe covid-19 pneumonia: pathogenesis and clinical management.

Severe covid-19 pneumonia has posed critical challenges for the research and medical communities. Older age, male sex, and comorbidities increase the risk for severe disease. For people hospitalized with covid-19, 15-30% will go on to develop covid-19 associated acute respiratory distress syndrome (CARDS). Autopsy studies of patients who died of severe SARS CoV-2 infection reveal presence of diffuse alveolar damage consistent with ARDS but with a higher thrombus burden in pulmonary capillaries. When used appropriately, high flow nasal cannula (HFNC) may allow CARDS patients to avoid intubation, and does not increase risk for disease transmission. During invasive mechanical ventilation, low tidal volume ventilation and positive end expiratory pressure (PEEP) titration to optimize oxygenation are recommended. Dexamethasone treatment improves mortality for the treatment of severe and critical covid-19, while remdesivir may have modest benefit in time to recovery in patients with severe disease but shows no statistically significant benefit in mortality or other clinical outcomes. Covid-19 survivors, especially patients with ARDS, are at high risk for long term physical and mental impairments, and an interdisciplinary approach is essential for critical illness recovery.

Endotracheal Tube Obstruction Among Patients Mechanically Ventilated for ARDS Due to COVID-19: A Case Series.

BACKGROUND: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing endotracheal tube (ETT) obstruction that has not been previously described in patients with ARDS due to other causes. The purpose of this report is to describe a case series of patients with COVID-19 and ARDS in which ETT occlusion resulted in significant clinical consequences and to define the pathology of the obstructing material. METHODS: Incidents of ETT occlusion during mechanical ventilation of COVID-19 patients were reported by clinicians and retrospective chart review was conducted. Statistical analysis was performed comparing event rates between COVID-19 and non-COVID 19 patients on mechanical ventilation over the predefined period. Specimens were collected and submitted for pathological examination. FINDINGS: Eleven COVID-19 patients experienced endotracheal tube occlusion over a period of 2 months. Average age was 69 (14.3, range 33-85) years. Mean APACHE III score was 73.6 (17.3). All patients had AKI and cytokine storm. Nine exhibited biomarkers for hypercoagulability. Average days on mechanical ventilation before intervention for ETT occlusion was 14 (5.18) days (range of 9 to 23 days). Five patients were discharged from the ICU, and 4 expired. Average documented airway resistance on admission was 14.2 (3.0) cm H2O/L/sec. Airway resistance before tube exchange was 28.1 (8.0) cm H2O /L/sec. No similar events of endotracheal tube occlusion were identified in non-COVID patients on mechanical ventilation during the same time period. Microscopically, the material consisted of mucin admixed with necrotic cell debris, variable numbers of degenerated inflammatory cells, oral contaminants and red blood cells. INTERPRETATION: Patients with COVID-19 and ARDS on prolonged mechanical ventilation are at risk for developing ETT obstruction due to deposition of a thick, tenacious material within the tube that consists primarily of mucin and cellular debris. Clinicians should be aware of this dangerous but treatable complication.

Multiplex Ventilation: A Simulation-Based Study of Ventilating 2 Patients With a Single Ventilator.

BACKGROUND: The overwhelming demand for mechanical ventilators due to COVID-19 has stimulated interest in using one ventilator for multiple patients (ie, multiplex ventilation). Despite a plethora of information on the internet, there is little supporting evidence and no human studies. The risk of multiplex ventilation is that ventilation and PEEP effects are largely uncontrollable and depend on the difference between patients' resistance and compliance. It is not clear whether volume control ventilation or pressure control ventilation is safer or more effective. We designed a simulation-based study to allow complete control over the relevant variables to determine the effects of various degrees of resistance-compliance imbalance on tidal volume (VT), end-expiratory lung volume (EELV), and imputed pH. METHODS: Two separate breathing simulators were ventilated with a ventilator using pressure control and volume control ventilation modes. Evidence-based lung models simulated a range of differences in resistance and compliance (6 pairs of simulated patients). Differences in VT, EELV, and imputed pH were recorded. RESULTS: Depending on differences in resistance and compliance, differences in VT ranged from 1% (with equal resistance and compliance) to 79%. Differences in EELV ranged from 2% to 109%, whereas differences in pH ranged from 0% to 5%. Failure due to excessive VT (ie, > 8 mL/kg) did not occur, but failure due to excessive EELV difference (ie, > 10%) was evident in 50% of patient pairs. There was no difference in failure rate between volume control and pressure control ventilation modes. CONCLUSIONS: These experiments confirmed the potential for markedly different ventilation and oxygenation for patients with uneven respiratory system impedances during multiplex ventilation. Three critical problems must be solved to minimize risk: (1) partitioning of inspiratory flow from the ventilator individually between the 2 patients, (2) measurement of VT delivered to each patient, and (3) provision for individual PEEP. We provide suggestions for solving these problems.

SARS-CoV-2 infection in the COPD population is associated with increased healthcare utilization: An analysis of Cleveland clinic's COVID-19 registry.

BACKGROUND: We sought to determine whether COPD conferred a higher risk for healthcare utilization in terms of hospitalization and clinical outcomes due to COVID-19. METHODS: A cohort study with covariate adjustment using multivariate logistic regression was conducted at the Cleveland Clinic Health System in Ohio and Florida. Symptomatic patients aged 35 years and older who were tested for SARS-CoV-2 between March 8 and May 13, 2020 were included. FINDINGS: 15,586 individuals tested for COVID-19 at the Cleveland Clinic between March 8, 2020 and May 13, 2020 met our inclusion criteria. 12.4% of COPD patients (164/1319) tested positive for COVID-19 compared to 16.6% (2363/14,267) of the non-COPD population. 48.2% (79/164) of COVID-19 positive COPD patients required hospitalization and 45.6% (36/79) required ICU admission. After adjustment for covariates, rates of COVID-19 infection were not significantly different than the non-COPD population (adj OR 0.97; CI: 0.89-1.05), but COPD patients had increased healthcare utilization as demonstrated by risk for hospitalization (adj OR 1.36; CI: 1.15-1.60), ICU admission (OR 1.20; CI: 1.02-1.40), and need for invasive mechanical ventilation (adj OR 1.49; CI: 1.28-1.73). Unadjusted risk for in-hospital mortality was higher in the COPD population (OR 1.51; CI: 1.14-1.96). After adjusting for covariates however, the risk for in-hospital mortality was not significantly different than the non-COPD population (adj OR 1.08: CI: 0.81-1.42). INTERPRETATION: Our analysis demonstrated that COPD patients with COVID-19 had a higher risk for healthcare utilization, although adjusted in-hospital mortality risk was not different than the non-COPD patients with COVID-19.

Management of patients with COPD during the COVID-19 pandemic.

Patients with COPD have an increased risk for severe COVID-19. Symptoms such as high-grade fever, anorexia, and myalgia may distinguish COVID-19 from dyspnea due to a COPD-related exacerbation. Management of COVID-19 in the patient with COPD may still warrant standard-of-care exacerbation treatment with antimicrobial agents and corticosteroids. Modalities to treat acute respiratory failure can be used with some caveats. Patients with COPD and COVID-19 infection who treat their illness at home should self-isolate, use nebulizers with precautions to avoid viral aerosolization, and frequently disinfect room surfaces.