How System-Wide Strategies Early in the COVID-19 Pandemic Improved ICU Outcomes

“These are the situations when you would rather overprepare,” says Peng Zhang, MD, a critical care physician in Cleveland Clinic’s Respiratory Institute. She was nearing the end of her fellowship around the time the coronavirus began circulating in the U.S.

Dr. Zhang, now an attending physician, along with Abhijit Duggal, MD, and Hassan Khouli, MD, Chair of the Department of Critical Care Medicine, set out to compare the clinical outcomes of ICU patients — both with COVID-19 and without — early in the pandemic. They published their findings in CHEST.

The study shows that the ICU and hospital mortality rates of patients with COVID-19 were significantly higher than non-COVID patients in March 2020 (both P < .001). However, by June 2020, there was no statistical difference (both P = .16) between the two cohorts. This was also true for hospital deaths, ICU length of stay, hospital length of stay and mechanical ventilation duration in the COVID-19 cohort. Meanwhile, ICU outcomes for the non-COVID-19 cohort remained relatively unchanged, according to the authors.

The authors acknowledge that the utilization of pharmacological interventions, like remdesivir and corticosteroids, may have helped improve clinical outcomes but alone are not attributable to the significant overall improvement in mortality rates.

Dr. Zhang explains that the improvement demonstrated in this study is greater than what has been documented in the literature about the effects of corticosteroids. And remdesivir is not associated with mortality reduction, according to a large study sponsored by the Hassan Khouli, MD

Cleveland Clinic: Key COVID-19 strategies

She notes that findings from their study are encouraging and not entirely surprising, but it’s still complicated. Adding to this, Dr. Khouli remarks, “The comparison to non-COVID ICU patients is complex since there are no risk-adjusted equations for COVID-19 now.” However, the authors are confident that several key strategies played a pivotal role in improving outcomes.

They outline the following system-wise strategies:

• Designation of cohort COVID-19 ICU in hubs across the healthcare system.
• Careful evaluation of ICU occupancy and a plan to manage and redistribute caseloads if needed.
• Deployment of COVID-19 specific training modules for all ICU providers.
• Standardized and evidence-based management of ICU care for patients with COVID-19.
• Collaboration across multidisciplinary teams, including critical care, infectious disease, nephrology and palliative care.

“To our knowledge, this is the first large case series to show continuous improvement in clinical outcomes for critically ill COVID-19 patients,” says Dr. Zhang. The authors are hopeful that in the face of another epidemic or pandemic, healthcare systems can readjust nimbly to meet the needs of patients.

She concludes, “For healthcare systems that are adequately resourced and prepared, system-wide strategies that are implemented early can be incredibly effective in improving outcomes.”

Editor’s note: Gretchen L. Sacha, PharmD (Department of Pharmacy); Joseph Keller, PA-C, MHS (Department of Critical Care Medicine); and Lori Griffiths, MPH, RN (Department of Quality and Patient Safety) are co-authors on this study.