As the novel coronavirus continues to spread, we are continuing to see areas affected with rapid spikes of cases. Dr. Anjali Acharya, a nephrologist and Dr. Matthew Langston, a pulmonary and critical care physician both from the Bronx-based Jacobi Hospital in New York City share their experiences working in this current coronavirus hotspot.
I remember first hearing about COVID-19 as a potential problem in February. Then, in early March, the drumbeat of news and planning began to accelerate. When did you first begin to hear about COVID-19 as a potential problem?
Dr. Acharya: Our first index case happened in New York on March 1. A woman in her 30s who had traveled from Iran arrived into Manhattan. A second case appeared around March 3 in Westchester, which is a suburb about 20 miles north of New York. This case was particularly important as the patient had no travel history. By then, I think we knew the disease was spreading within the community.
At Jacobi Hospital, our first patient arrived in the Bronx on about March 13 or 14. I remember that patient vividly as we consulted on that patient. Afterwards, we found out that his family was visiting from Italy. I believe that was how he was infected.
From there on, it took off. Within the next few days, we started seeing patients rolling in through our emergency room quite rapidly.
When do you remember the planning phases beginning at your institution?
Dr. Langston: In early March, we started to lay groundwork for our hospital's response. We are one of eleven acute care facilities in the New York Public Health System. From an administrative standpoint, there were challenges in coordinating between the hospitals and balancing their individual approaches, especially as there were different time frames when different communities were being hit hard. Elmhurst Hospital in Queens was quickly hit hard, very quickly and overrun about a week before our hospital’s cases started to pick up.
Was there advance thought about the need for more equipment? For example, much of what we're hearing in the news media is about a shortage of ventilators. At a hospital level, were you thinking about your ventilator capacity and trying to acquire more ventilators, if they were even available?
Dr. Langston: At a system level, those conversations were being had very early on. At the individual hospital level, the pace of this went from 0 to 60 very quickly. I remember we nearly doubled our ventilator capacity in a handful of days.
While those conversations started early, they probably did not contain enough earnestness, as no one quite knew what to expect. Additional efforts increased as more cases presented throughout the New York area. Given New York City area hospitals being what they are, and by extension, hospitals across the country, everyone's asking for the same thing. It's been very challenging to get some equipment, although we have been able to share resources within our health system.
I imagine that one challenge is the size of New York City. Given that populations are different and that clusters of cases were occurring at different times in different parts of the city, it’s most likely made planning across a large hospital system very difficult. Tell us more about the profile of the patients who are developing critical illness and are requiring Intensive Care Unit (ICU) care.
Dr. Langston: We have seen a lot of patients who are older, although admittedly, I think there have been a lot of deaths in the community. We're surrounded by a large number of nursing homes. Where we are in the Bronx, it's an underserved and under resourced part of New York. Our patients tend to come in very late with any medical problem. I think a lot of our oldest patients didn't make it to the hospital or didn't make it out of the emergency room.
The patients that have made it into our intensive care unit are of a significant cohort. These are young, fairly healthy individuals aged 30s to 60s with maybe mild obesity or diabetes. Some certainly have more complex problems. However, we've seen patients that truly come in with high burden of comorbidities, who tend to get really sick very quickly and tend to not do well. They tend to die early. These patients—ultimately, our ICU populations have in a sense, self-selected based on the ability to weather the initial parts of this disease.
For your patients who are not in the ICU, what are you monitoring to trigger a transfer to an ICU setting?
Dr. Langston: At the simplest level, we are trying to guide our triage by oxygen saturation and then assessment of respiratory work. We've borrowed guidelines from other colleagues in other institutions. If someone starts to desaturate below 94%, that's our initial threshold for starting nasal cannula. If again, they come down to 94% or less, we're usually moving straight to a non-rebreather to minimize risk of aerosolization. Once those patients are in the mid to low 90s, that's when our critical care team is being deployed to evaluate.
Originally, our pulmonary team was overwhelmed with the number of patient consults and the mild to moderate disease on nasal cannula. We've had to recalibrate our set points for critical care consults, for deployment of different resources based on availability and severity of cases. The paradigm has shifted a little bit in terms of the burden of illness. That's how our teams are managing.
I've heard some institutions are trying proning patients on the floor before they get to the ICU. Are you employing this strategy at your institution?
Dr. Langston: We started proning patients in the last few weeks. It's one of those moments in medicine where when we tried this; we asked ourselves ‘why weren’t we doing this before?’ We have a simple protocol where for six-hour periods, we have the patient either prone or in decubitus, one side to another, along with some other breathing maneuvers.
It's somewhat difficult to comply with as it's uncomfortable. It's a challenge to sometimes get our patients to be consistent with the recommendation. We're definitely trying to employ proning patients more, as aggressively as we can and as early as we can.
Again, this is all in the midst of what's evolving. Anecdotally, it does seem to have at least helped stabilize some patients. I do think we avoided intubation in some patients with whom we started this early on.
What about non-invasive ventilation, things like BiPap? I've heard concerns about BiPap in terms of aerosolization of the virus. Are you using BiPap or other non-invasive strategies?
Dr. Langston: That's a very interesting question and interesting point. The discussion around respiratory management of this disease, whether it's intubating early, intubating later—do we use non-invasive high-flow or not? Everything is dynamic and evolving quickly, oftentimes based on the experience of others who are ahead of us in caring for this disease process.
Early on, we were avoiding routinely using high-flow and BiPap. Our hospital's infrastructure has a limited number of true negative pressure rooms, which are the ideal rooms to use if we have those means of support deployed. All of those rooms would be filled by patients who are more ill to minimize the use.
There has been a transition over the past week to a more liberal use of high-flow nasal cannula, both pre and post-extubation, as well as limited trials of BiPap. This is an experience that's definitely evolving. However, this is one area where we're encountering some resource limitations, both in terms of the number of high-flow machines as well as the tubing for the high-flow and BiPap. At this point, the need for noninvasive is outstripping our capacity to provide it.
Is your hospital participating in any clinical trial?
Dr. Langston: We are. Our research department was able to ramp up multiple clinical trials. We are in clinical trials for sarilumab, an IL-6 receptor blocker. That's aimed at intervening in the "cytokine storms surge." In the last week, we have started ramping up a trial of remdesivir as well. We've had some of those agents for our patients, which has been great.
Are there any final thoughts you want to leave us with or pieces of advice for cities that will reach their peaks later?
Dr. Langston: It’s important to be flexible and realize that everyone is going to be asked to operate out of their usual sphere of comfort. This can mean different things, from having obstetricians help run more medicine teams or having dental anesthesia residents help run step down units.
We have tried to learn to balance patient care with mitigating risk to staff. In the ICU, that's led to some very practical changes. We have all of our IV pumps out of the room. Other facilities have found ways to remove the ventilator control unit out of the room. Even some institutions are doing CBBH out of the room.
We try to balance minimizing personal contact to times when we think it will benefit patient management, which is not the usual paradigm. Our usual paradigm is to go the patient’s bedside and do a thorough examination. However, realizing that there's a real risk to staff, recalibrates things.
Finally, it’s crucial to be clear and intentional in how communication happens through your hospital, from the CEO’s office to all staff. There is such a deluge of communication, both internally and externally, as new reports and studies continue to churn out. It's really easy to get lost. It's especially easy for important details and lessons being applied at your hospital to get lost in the hundreds of emails that are sent every day. Having a clearly established way of communicating is critical.
This interview is part two of a two-part series adapted from the Lessons Learned from Around the World in Dealing with COVID-19 webinar recorded on April 9, 2020.