Hospitals across the country faced a quandary when the COVID-19 pandemic hit their communities: how would doctors treat a completely new and unknown disease?
Throughout the last 20 months, health systems harnessed rapidly unfolding research as they selected the strategies to help patients survive the virus.
“This was real-time learning and flying by the seat of your pants and trying to do the best that you can, using scarce data that is then dramatically transformed to exponential data,” said Arif Sarwari, chairman for the department of medicine at the West Virginia University School of Medicine.
Sawari led the charge on setting up weekly teleconference calls with leadership within the department at the academic medical center in Morgantown, West Virginia. Every week, one doctor would be tasked with pulling together a seven-minute Powerpoint presentation on the latest studies. Based on that research, pharmacy leaders were pulled in to develop clinical protocols.
St. Luke’s University Health Network, which spans 12 hospitals across Pennsylvania and New Jersey, launched a 25-person COVID-19 response team to scour research. It included staff from disciplines like pharmacy and nursing to environmental services and food services. The task force also kept abreast of what research was showing as smaller studies developed into large-scale clinical trials.
“In the beginning, there was a major use of hydroxychloroquine,” said Dr. Jeffrey Jahre, the vice president of medical affairs at of St. Luke’s. “And then it became very clear that hydroxychloroquine was not the answer. Sometimes those protocols would change on a daily basis depending on what the science was.”
Treatment protocols were disseminated in any way clinicians could receive them: through emails, newsletters, printouts at the bedside and online intranets. At the same time, infectious disease hospital leaders also assessed outcomes data. NYU Langone Health tapped its chief quality officer and chief of epidemiology to create COVID-19 dashboards that helped monitor how many patients were coming in, length of stay and outcomes.
That kind of observational data came into play after NYU Langone conducted autopsies of some patients and found that many had blood clots not just in their lungs, but throughout their organs. The health system started putting COVID-19 patients on blood thinners.
“We all recognized that we were trying to do this based on observational data, the best evidence we could have,” said Dr. Fritz Francois, executive vice president and chief of hospital operations at NYU Langone Health.
NYU Langone and many other hospitals started conducting trials to dissect which types of blood thinners worked best at what dosage. Though COVID-19 symptoms varied vastly, there were commonalities among patients and getting a regime right was important.
This kind of rapid change is unusual for clinical care. For the most part, there are treatment guidelines for most diseases and doctors have years of experience treating them. Organizations like the Centers for Disease Control and Prevention and the Infectious Disease Society of America released living document treatment guidelines, but they were only so helpful.
“They’ll say, ‘use monoclonal antibodies in outpatients that have certain comorbidities and are at high risk for development,’ but how you actually do that is a significant barrier and you really need a multidisciplinary team to figure that out,” said Dr. Thomas Walsh, an infectious disease specialist and medical director of Allegheny Health Network’s antimicrobial stewardship program.
Health systems added operations and logistics staff to the task force to solve issues like drug shortages, supply chain hiccups and low staffing. Most hospitals don’t have empty space available to set up a monoclonal antibody clinic on the fly, and nursing shortages could jeopardize staffing for one-hour treatments and one-hour recovery time per patient.
Clinicians are now watching for research on repurposed drugs like selective serotonin reuptake inhibitors that usually treat depression, but show some early promise for treating COVID-19, and on whether inhaled steroids might be more effective than IV or pill versions. But more high-quality data is needed before hospitals will add these to treatment regimens.
The next big thing is what treatment will look like in outpatient clinics, with some experts comparing that step to managing the flu.
“Even when we end the pandemic, this is a virus. It’s going to be endemic like seasonal influenza,” said Walsh from AHN. “And so what we need to do is defang the virus, so it doesn’t kill nearly as many people, it doesn’t hospitalize many people and we’re able to treat many more patients in the outpatient setting.”
Blood thinners could be part of that outpatient treatment. A recent study found outpatient COVID-19 patients on blood thinners were hospitalized less than those who weren’t already on the drugs. For now, study author Dr. Sameh Hozayen recommends that doctors use the study findings to promote medication adherence among patients already prescribed the drugs, because blood thinners carry risks.
“For example, they’re brushing their teeth, and they can bleed to death; It’s not something you can just tell primary care physicians to prescribe to everyone,” said Hozayen, a professor at the University of Minnesota Medical School.