Faculty Bibliography

Infectious disease outbreaks and pandemics have repeatedly threatened public health and have severely strained healthcare delivery systems throughout the past century. Pathogens causing respiratory illness, such as influenza viruses and coronaviruses, as well as the highly communicable viral hemorrhagic fevers, pose a large threat to the healthcare delivery system in the United States and worldwide. Through the Hospital Preparedness Program, within the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, a nationwide Regional Ebola Treatment Network (RETN) was developed, building upon a state- and jurisdiction-based tiered hospital approach. This network, spearheaded by the National Emerging Special Pathogens Training and Education Center, developed a conceptual framework and plan for the evolution of the RETN into the National Special Pathogen System of Care (NSPS). Building the NSPS strategy involved reviewing the literature and the initial framework used in forming the RETN and conducting an extensive stakeholder engagement process to identify gaps and develop solutions. From this, the NSPS strategy and implementation plan were formed. The resulting NSPS strategy is an ambitious but critical effort that will have impacts on the mitigation efforts of special pathogen threats for years to come.

BACKGROUND:After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of ongoing surges throughout the world. METHODS:The Task Force for Mass Critical Care (TFMCC) adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS:Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. CONCLUSIONS:A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

INTRODUCTION: Hospitals experienced substantial stress during the COVID-19 pandemic-threats to standard operations- but it is not well known how this stress manifested at individual hospitals. We aimed to understand patterns of hospital stress over time, where stress was located within hospitals, and correlations between individual stress measures.
METHOD(S): We conducted a weekly hospital stress survey from November 2020 through May 2021 among site leaders from the SCCM Discovery Severe Acute Respiratory Infection - Preparedness (SARI-PREP) multicenter prospective cohort study. The survey assessed hospital stress ordinally and also assessed ED and ICU stress and deviations from standard operating procedures. Pairwise comparisons of strain measures were calculated by Pearson's correlation coefficients (r).
RESULT(S): Eight hospitals across three health systems in New York, California, and Washington contributed 190 hospital-weeks of data. Sites reported unavailability of some hospital resources resulting in potentially avoidable patient harm during 3.5% of hospital-weeks (with at least one such week at four hospitals); alterations in care processes and/or staffing which were fully compensated for during 57.9% of weeks; and no stress during 38.6% of weeks. During one December 2020 week, hospital stress, ICU stress, and care deviations were all present at 100% of reporting sites. The most common care deviations were increased hospital staffing (39.5%) and cancelling elective surgeries (18.6%). Hospital stress and care deviations were highly correlated (r = 0.81, p < 0.0001). Stress was more common in ICUs (72.4%) than EDs (14.3%), and ICU and ED stress were not correlated (r = 0.19, p = 0.05). While ED stress rose and abated earlier, ICU stress and care deviations persisted (range 2-13 weeks longer) as local case rates declined.
CONCLUSION(S): Hospital stress during the pandemic varied in degree and type both within and among hospitals over time. Care deviations were common but potentially avoidable patient harm was rare. Systematic national assessments of hospital stress, both during and between pandemics, could inform more rapid, proactive public health responses to novel threats. Areas for further study include impacts from persistent low-level stress and longer-term consequences for hospitals and their communities

OBJECTIVES: We designed a prospective cohort study to systematically study patients with severe acute respiratory infection (SARI) and improve hospital preparedness (SARI-PREP). The goal of this project is to evaluate the natural history, prognostic biomarkers, and characteristics, including hospital stress, associated with SARI clinical outcomes and severity.
METHOD(S): In collaboration with the Society of Critical Care Medicine Discovery Research Network and the National Emerging Special Pathogen Training and Education Center (NETEC), SARIPREP is an ongoing, prospective, observational, multi-center cohort study of hospitalized patients with respiratory viral infections. We collected patient demographics, signs, symptoms, and medications; microbiology, imaging, and other diagnostics; mechanical ventilation, hospital procedures, and other interventions; and clinical outcomes. Hospital leadership completed a weekly hospital stress survey. Respiratory, blood, and urine biospecimens were collected from patients on days 0, 3, 7-14 after study enrollment and at hospital discharge. MEASUREMENTS AND MAIN RESULTS: SARI-PREP enrollment began on April 4, 2020 and currently includes 674 patients. Here we report results from the first 400 patients: 216 are from the University of Washington Hospitals, Seattle WA, 142 from New York University, New York NY and 42 from University of Southern California, Los Angeles, CA. Almost all tested positive for SARS-CoV-2 infection (n=397), whereas 3 patients tested positive for an alternative viral pathogen. The mean (+/-SD) age of the patients was 57+/-16 years; 72% were men, 62% were White, 14% were Asian, 12% were Black, and 31% were Hispanic. Most of the patients were admitted to the intensive care unit (96%). The median (interquartile range) hospital length of stay was 22 (9-46) days. Rates of invasive mechanical ventilation (72%) and renal replacement therapy (19%) were common and the rate of hospital mortality was 35%.
CONCLUSION(S): Initial SARI-PREP analysis indicates enrollment of a diverse population of hospitalized patients primarily with SARSCoV-2 infection. The demographics and clinical outcomes of our cohort mirror other large critically ill cohorts of COVID-19 patients. Results of a concomitant, weekly, hospital stress assessment are reported separately

BACKGROUND:The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity. METHODS:This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center. RESULTS:Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period. CONCLUSION/CONCLUSIONS:These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.

Introduction: Tracheostomy in COVID-19 patients is a controversial and difficult clinical decision. A recent COVID-19 Severity Score (CSS) was validated to identify high-risk patients requiring hospitalization. We hypothesized that the CSS would be associated with survival in patients considered for tracheostomy.
Method(s): We reviewed 77 mechanically ventilated COVID-19 patients evaluated for percutaneous dilational tracheostomy (PDT) from March-June 2020 at a public tertiary care center. Decision for PDT was based on clinical judgment of the screening surgeons. The CSS was retrospectively calculated using mean biomarker values from admission to time of PDT consult. Primary end point was survival to discharge. The Youden index identified an optimal CSS cut point for survival.
Result(s): Mean CSS for 42 survivors vs 35 nonsurvivors was significantly different (CSS 52 vs 66; p = 0.003). The Youden index returned an optimal CSS of 55 (area under the curve 0.7; 95% CI, 43 to 72). Median CSS was 40 (interquartile range 27 to 49) in the Low CSS (<55 group) and 72 (interquartile range 66 to 93) in the high CSS (>= 55) group (Fig. 1a). Eighty-seven percent of low CSS patients underwent PDT, with 74% survival, and 61% of high CSS patients underwent PDT with only 41% surviving (Fig. 1b). Patients with high CSS had 77% lower odds of survival (odds ratio 0.2; 95% CI, 0.1 to 0.7).
Conclusion(s): Higher CSS was associated with decreased survival to discharge in patients evaluated for PDT, with a score > 55 predictive of mortality. The novel CSS can be a useful adjunct in determining which COVID-19 patients will benefit from tracheostomy. Further prospective validation of this tool is warranted. [Formula presented]
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BACKGROUND:The novel coronavirus-associated ARDS (COVID-19 ARDS) often requires invasive mechanical ventilation. A spectrum of atypical ARDS with different phenotypes (high vs low static compliance) has been hypothesized in COVID-19. METHODS:test, chi-square test, ANOVA test, and Pearson correlation was used to identify relationship between subject variables and respiratory mechanics. The primary outcome was duration of mechanical ventilation. Secondary outcomes were correlation between fluid status, C- reactive protein, PEEP, and D-dimer with respiratory and ventilatory parameters. RESULTS:= .02). CONCLUSIONS:In our cohort of mechanically ventilated COVID-19 ARDS subjects, high PEEP and D-dimer were associated with increase in physiologic dead space without significant effect on oxygenation, raising the question of potential microvascular dysfunction.

Respiratory failure is associated with increased mortality in COVID-19 patients. There are no validated lower airway biomarkers to predict clinical outcome. We investigated whether bacterial respiratory infections were associated with poor clinical outcome of COVID-19 in a prospective, observational cohort of 589 critically ill adults, all of whom required mechanical ventilation. For a subset of 142 patients who underwent bronchoscopy, we quantified SARS-CoV-2 viral load, analysed the lower respiratory tract microbiome using metagenomics and metatranscriptomics and profiled the host immune response. Acquisition of a hospital-acquired respiratory pathogen was not associated with fatal outcome. Poor clinical outcome was associated with lower airway enrichment with an oral commensal (Mycoplasma salivarium). Increased SARS-CoV-2 abundance, low anti-SARS-CoV-2 antibody response and a distinct host transcriptome profile of the lower airways were most predictive of mortality. Our data provide evidence that secondary respiratory infections do not drive mortality in COVID-19 and clinical management strategies should prioritize reducing viral replication and maximizing host responses to SARS-CoV-2.