When the COVID-19 pandemic hit their communities, hospitals across the country faced a dilemma: How will doctors treat a new and unknown disease?
In the past 20 months, the health system has taken advantage of rapidly expanding research in choosing strategies to help patients fight the virus.
“It’s real-time learning and flying, and trying to do your best to use scarce data, and then dramatically convert these data into exponential data,” said Arif Savari, head of the Department of Medicine. West Virginia University School of Medicine.
Sawari is responsible for establishing weekly conference calls with department leaders at the Academic Medical Center in Morgantown, West Virginia. Each week, a doctor’s task is to compile a 7-minute Powerpoint presentation on the latest research. Based on this research, pharmacy leaders were drawn in to develop clinical protocols.
The St. Luke’s University Health Network, which spans 12 hospitals in Pennsylvania and New Jersey, established a COVID-19 response team of 25 people to conduct research. It includes employees in subjects ranging from pharmacy and nursing to environmental services and food services. As small research develops into large-scale clinical trials, the working group is also kept abreast of research results.
“In the beginning, hydroxychloroquine was mainly used,” said Dr. Jeffrey Jahre, vice president of medical affairs at St. Luke’s. “Then it is clear that hydroxychloroquine is not the answer. Sometimes these protocols change every day, depending on what the science is.”
The treatment plan is disseminated in any way that clinicians can receive: via email, newsletters, bedside printouts, and online intranets. At the same time, the leaders of the infectious disease hospital also evaluated the result data. NYU Langone Health hired its chief quality officer and epidemiology director to create a COVID-19 dashboard to help monitor the number of patients entering, length of stay and results.
After performing an autopsy on some patients at NYU Langone and finding that many patients had blood clots not only in the lungs, but also in the entire organs, this observation data came into play. The health system began to allow COVID-19 patients to take blood thinners.
Dr. Fritz François, Executive Vice President and Head of Hospital Operations at New York University Lange Health Hospital, said: “We all recognize that we are trying to do this based on observational data. This is the best we can have. Good evidence.”
New York University Langone and many other hospitals have begun trials to analyze which type of blood thinner works best at which dose. Although the symptoms of COVID-19 vary widely, there are commonalities among patients, so it is important to develop the correct treatment plan.
This rapid change is unusual for clinical care. In most cases, most diseases have treatment guidelines, and doctors have many years of experience in treating these diseases. Organizations such as the Centers for Disease Control and Prevention and the American Academy of Infectious Diseases have issued guidelines for treatment of life documents, but their help is very limited.
“They would say,’Use monoclonal antibodies in outpatients with certain comorbidities and high risk of development,’ but how do you actually do this is a major obstacle. You really need a multidisciplinary team to come. Solve this problem,” the doctor said. Thomas Walsh, infectious disease expert and medical director of the Allegheny Health Network Antibacterial Management Program.
The health system has added operations and logistics staff to the working group to address drug shortages, supply chain issues, and staff shortages. Most hospitals do not have the free space available to quickly establish monoclonal antibody clinics, and the shortage of nursing staff may endanger the staffing of one hour of treatment and one hour of recovery time for each patient.
Clinicians are now looking at research on reusing drugs, such as selective serotonin reuptake inhibitors that usually treat depression but show some early promise, and whether inhaled steroids may be more effective than intravenous injections or pills. But before the hospital can add these data to the treatment plan, more high-quality data is needed.
The next big thing is the treatment method in the outpatient clinic. Some experts compare this step with the way doctors handle the flu.
“Even if we end the pandemic, this is a virus. It will be epidemic like seasonal flu. It will not disappear,” said Walsh of AHN. “So what we need is to eliminate the virus, so it won’t kill so many people, won’t make many people hospitalized, and we can treat more patients in outpatient clinics.”
Blood thinners may be part of outpatient treatment. A recent study found that the hospitalization rate of COVID-19 patients who use blood thinners is lower than that of patients who have not yet been treated for other diseases. For now, the study author, Dr. Sameh Hozayen, recommends that doctors use the results of the study to promote medication compliance for patients who have been prescribed medications because blood thinners have some risks.
“For example, they may bleed to death while brushing their teeth; this is not a medicine you can tell a primary care doctor to prescribe everyone,” said Hozayen, a professor at the University of Minnesota School of Medicine.