key: cord-1049058-qgjp103m
authors: Mitchell, Oscar J.L.; Neefe, Stacie; Ginestra, Jennifer C.; Baston, Cameron M.; Frazer, Michael J.; Gudowski, Steven; Min, Jeff; Ahmed, Nahreen H.; Pascual, Jose L.; Schweickert, William D.; Anderson, Brian J.; Anesi, George L.; Falk, Scott A.; Shashaty, Michael G.S.
title: Impact of COVID-19 on inpatient clinical emergencies: A single-center experience
date: 2021-05-04
journal: Resusc Plus
DOI: 10.1016/j.resplu.2021.100135
sha: 1d01c607d331ddecb0aab89129ba66ef7d140786
doc_id: 1049058
cord_uid: qgjp103m

AIM: Determine changes in rapid response team (RRT) activations and describe institutional adaptations made during a surge in hospitalizations for coronavirus disease 2019 (COVID-19). METHODS: Using prospectively collected data, we compared characteristics of RRT calls at our academic hospital from March 7 through May 31, 2020 (COVID-19 era) versus those from January 1 through March 6, 2020 (pre-COVID-19 era). We used negative binomial regression to test differences in RRT activation rates normalized to floor (non-ICU) inpatient census between pre-COVID-19 and COVID-19 eras, including the sub-era of rapid COVID-19 census surge and plateau (March 28 through May 2, 2020). RESULTS: RRT activations for respiratory distress rose substantially during the rapid COVID-19 surge and plateau (2.38 (95% CI 1.39–3.36) activations per 1000 floor patient-days v. 1.27 (0.82–1.71) during the pre-COVID-19 era; p = 0.02); all-cause RRT rates were not significantly different (5.40 (95% CI 3.94–6.85) v. 4.83 (3.86–5.80) activations per 1000 floor patient-days, respectively; p = 0.52). Throughout the COVID-19 era, respiratory distress accounted for a higher percentage of RRT activations in COVID-19 versus non-COVID-19 patients (57% vs. 28%, respectively; p = 0.001). During the surge, we adapted RRT guidelines to reduce in-room personnel and standardize personal protective equipment based on COVID-19 status and risk to providers, created decision-support pathways for respiratory emergencies that accounted for COVID-19 status uncertainty, and expanded critical care consultative support to floor teams. CONCLUSION: Increased frequency and complexity of RRT activations for respiratory distress during the COVID-19 surge prompted the creation of clinical tools and strategies that could be applied to other hospitals.

The worldwide spread of SARS-CoV-2 has resulted in surges of hospitalizations in patients with COVID-19 respiratory illness 1 . Despite pandemic control efforts, the United States continues to see such In response, our hospital clinical emergencies leadership team launched a series of efforts to rapidly adapt existing guidelines, generate simple clinical tools for guideline application, and disseminate such tools to clinical personnel. In this study, we aimed to determine differences in rates and characteristics of RRT activations during the spring 2020 surge of COVID-19 patient admissions compared with the pre-COVID time period. Further, we sought to describe our hospital's early COVID-19 clinical emergencies experience and the systems adapted to permit delivery of emergent, safe treatment to rapidly deteriorating non-ICU inpatients.

J o u r n a l P r e -p r o o f

We performed a retrospective analysis of all inpatient RRT activations at HUP from January 1 through May 31, 2020. This time period included a "COVID era" starting with the first COVID-19 inpatient admission on March 7, 2020 and a "pre-COVID era" from January 1 through March 6, 2020.

The COVID era included the surge, plateau, and initial decline of COVID-19 inpatient census at HUP.

HUP is an academic 791-bed hospital that serves a diverse population of medical and surgical patients from the local West Philadelphia neighborhood and as a referral center for the greater Philadelphia region. The HUP rapid response system was established in July 2006 with a principal goal of providing timely, coordinated, multidisciplinary care to clinically deteriorating floor (non-ICU) inpatients.

The afferent limb can be activated by hospital staff or family 3 . The efferent limb, staffed at all times, includes medical and surgical RRTs as well as a range of specialist teams for critical care consultation, emergency intubation, surgical airway, and extracorporeal membrane oxygenation. Core RRT personnel include a critical care nurse, respiratory therapist, pharmacist, patient transporter, security personnel, and providers specific to RRT type: internal medicine residents and a medical critical care attending physician for medical RRT, surgical residents and a surgical critical care fellow for surgical RRT. These teams are alerted through dedicated pager and overhead announcements. Clinical details of each RRT activation are entered immediately after the event into a clinical emergencies quality improvement database by the RRT's critical care nurse. All COVID-19 diagnoses during the study period were made J o u r n a l P r e -p r o o f using a polymerase chain reaction (PCR) assay for SARS CoV-2. Multiple PCR test kits and reagents were used across the study period since no single assay had supply to meet testing needs.

We used χ2, Fisher's exact, and t-tests, as appropriate, to compare RRT patient, treatment, and outcome characteristics both by COVID era versus pre-COVID era and, within the COVID era, by COVID-19 status. We tested differences in RRT activation rates by era using negative binomial regression models to account for non-normal distribution. Stata/IC v. 16.0 (College Station, TX) and Microsoft Excel (Microsoft Office Professional Plus 2016) were used for statistical analyses. The study was deemed exempt by the University of Pennsylvania's Institutional Review Board.

During the COVID era, the RRT was activated for 165 floor inpatient emergencies: 147 medical and 18 surgical. Of note, during this timeframe all COVID-19-positive floor patients were cohorted and managed by internal medicine teams. Patient demographic and clinical characteristics, interventions during the RRT call, and disposition immediately after the RRT call and on hospital discharge are shown in Table 1 . The median RRT event duration was slightly longer during the COVID era than the pre-COVID era (38 v. 34 minutes, respectively, p=0.03), and was longer for COVID-19/PUI patients (those with a positive SARS-CoV-2 test or persons under investigation with a pending test) than those without COVID-19 (46 v. 35 minutes, respectively, p=0.04). Respiratory distress prompted 36% of RRT activations during the COVID era, compared with 26% during the pre-COVID era. Correspondingly, endotracheal intubation during RRT activations was more than twice as common during the COVID era, though we did not detect J o u r n a l P r e -p r o o f a significant difference by COVID-19 status. Among COVID era patients, RRT calls for respiratory distress were significantly more common in COVID-19/PUI patients than non-COVID-19 patients (57% v. 28%, p<0.01). In 18 of 35 RRT calls for respiratory distress in non-COVID-19 patients during the COVID era, new testing for SARS-CoV-2 was prompted by the clinical emergency. Of these, two tests (11%) were positive and the patients were diagnosed with COVID-19. Both of these patients had a prior negative test for SARS-CoV-2 during their hospitalizations. We did not detect significant differences in hospital discharge J o u r n a l P r e -p r o o f disposition for RRT patients between the COVID era versus the pre-COVID era, or between COVID-19/PUI versus non-COVID-19 patients during the COVID era (Supplemental Table 1 ).

COVID-19 had a significant impact on the nature of inpatient floor clinical emergencies at our institution, particularly during the surge and plateau of COVID-19 hospitalizations from late March to early May 2020. RRT call rates for respiratory decompensation were significantly more common during this time, driven by events in COVID-19/PUI patients. We think that these findings, and our efforts to create comprehensive and accessible management guides described in the following sections, are informative for hospital rapid response systems adapting to periods of rising or persistently elevated COVID-19 census.

We found that new testing for SARS-CoV-2 was prompted in over half of non-COVID-19 patients with respiratory-related clinical emergencies and was positive in a small number of cases. With multiple COVID-19 case rate surges since the onset of the pandemic, recognizing the potential for previously uninfected inpatients to acquire infection, whether from visitors or hospital personnel, takes on added importance when multiple providers emergently respond and may need to employ aerosol-generating interventions. Although our study was not designed to track rates of healthcare worker SARS-CoV-2 exposure and conversion, our findings suggest that inpatient clinical emergencies, particularly with new respiratory decompensation, may be the first indication of new COVID-19 that could put personnel at risk. We therefore suggest a systematic approach to infection control, PPE, and clinical decision making that accounts for uncertainties in COVID-19 status, outlined below. Such an approach can be tailored to an individual hospital based on PPE availability, local COVID-19 prevalence, and center-specific SARS-CoV-2 testing protocols and turnaround time.

Many of our initial modifications to clinical emergencies protocols were based on the limited data available at the time and iterative change informed by clinician feedback. Adapting procedures to limit transmission of infection to healthcare workers providing emergency care was of paramount concern.

We considered a spectrum of risk based on COVID-19 status and likelihood of aerosolgenerating procedures for each emergency type (Figure 2 , section on PPE and Infection Control). After several early experiences that highlighted the challenge of definitively establishing risk to providers at RRT onset, we adopted aggressive infection control guidelines particularly for patients with respiratory decompensation or cardiac arrest. We applied this approach even in patients not known to have COVID-19, though RRT personnel could de-escalate during events if an alternative diagnosis were established clearly enough that a new diagnosis of COVID-19 would not be entertained. We also reduced in-room personnel to only those essential for delivering emergency care (n=4 for RRT call, 7 for cardiac arrest, with the option to call in additional personnel as needed; Figure 3) , though no changes were made to the overall make-up of the responding team.

Reducing in-room personnel and routinely keeping the patient's door closed had significant impact on RRT communication. Some providers noted that the quieter, less crowded environment facilitated team communication within the patient's room. We did, however, have to institute procedures to enable communication with key team members, such as the pharmacist and additional nursing and physician staff, who stayed outside the patient room. The simplest measure, effective regardless of whether the room was visible from the outside via window or glass door, was to use an inroom phone on speaker setting connected to the lead nurse stationed just outside of the room. This 

As noted, respiratory clinical emergencies surged during the initial increase in patients hospitalized with COVID-19. Recommendations regarding allowable levels of non-invasive respiratory support, thresholds for intubation, and risks to both patient and personnel of such interventions changed during the early months and differed substantially from routine pre-COVID practice 4 . Of particular concern was the balance of risks--aerosolizing viral particles, patient instability-considered when deciding to intubate known or suspected COVID-19 patients in non-negative pressure rooms versus delaying intubation and transferring spontaneously breathing critically ill patients through hospital hallways to the ICU of the closest negative pressure room.

In response, we created a clinical decision support tool for respiratory decompensations that accounted for the urgency of intubation, the likelihood of COVID-19 infection, and competing infection control considerations (Supplemental Figure 1A and B) . Anticipating that recommendations would likely evolve, we embedded a hyperlink within the tool that brought the user to the most updated version which was maintained on a secure cloud storage server.

Given early reports of unusually rapid respiratory decompensation in COVID-19 pneumonia patients offer early engagement and integrated support for COVID-19 floor patients with concerning respiratory trajectories that had not yet prompted a RRT call. This adaptation also facilitated dissemination of emerging, novel therapies such as awake proning, ensured contingency planning for high-risk COVID-19 patients, and promoted timely goals of care discussions to guide further escalation of care if needed.

RRT and primary teams had substantial concern about viral spread from aerosol-generating procedures during cardiopulmonary resuscitation. Interim guidance from the American Heart Association, issued in April 2020, allowed for modification of resuscitation protocols in patients with COVID-19, such as replacing bag-valve-mask ventilation with application of oxygen without ventilation 7 .

Because clinical decompensations often raised the possibility of COVID-19 diagnosis even in those previously considered low risk, however, we were concerned that such a guideline change would lead to unnecessarily broad withholding of potentially lifesaving positive pressure ventilation. Further, our clinical experience with decompensating COVID-19 patients frequently involved rapidly worsening hypoxemia and hypercapnia requiring immediate positive pressure ventilation via bag-valve-mask to prevent respiratory or cardiac arrest.

We therefore focused heavily on PPE use and required use of high-efficiency particle air (HEPA) filters and two-provider technique to minimize the risk of aerosolization during bag-valve-mask ventilation (Figure 2) . HEPA filters were kept with bag-valve masks on all hospital code carts and carried by all respiratory therapists and RRT nurses. We also purchased several mechanical compression devices early in our COVID-19 surge to reduce both the number of in-room personnel needed for cardiopulmonary resuscitation and the exposure of those assigned to chest compressions. These devices were deployed in areas of the hospital with the greatest density of COVID-19 patients.

Rapidly modifying and communicating our RRT protocols proved challenging given the complexity of clinical emergencies management. For example, implementing stricter infection control measures created barriers to rapid patient assessment as well as communication between in-room personnel and support staff. We overcame such hurdles by actively seeking real-time feedback from RRT providers across disciplines, which, combined with the use of links to updated versions embedded within posted guideline summaries, allowed for rapid incorporation and dissemination of evolving recommendations.

With a stretched hospital workforce and multiple simultaneous patient management changes during the COVID-19 surge, we were unable to discretely and formally test the impact of our clinical emergencies interventions. Even if we were able to demonstrate specific benefit of summary tip sheets and additional layers of critical care and anesthesia support for floor teams, applying similar interventions more broadly would require customization to each hospital's rapid response system structure. J o u r n a l P r e -p r o o f Table 1 . Characteristics of, interventions for, and disposition of patients for whom the rapid response team was activated, by era and COVID-19 status.

Comparison by COVID-19 status (COVID era only)

COVID-19 Hospitalization Data: Laboratory Confirmed COVID-19-Associated Hospitalizations

A Machine Learning Algorithm to Predict Severe Sepsis and Septic Shock: Development, Implementation, and Impact on Clinical Practice

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19)

Facing Covid-19 in Italy -Ethics, Logistics, and Therapeutics on the Epidemic's Front Line. The New England journal of medicine

COVID-19 and Risks Posed to Personnel During Endotracheal Intubation

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With The Guidelines-Resuscitation Adult and Pediatric Task Forces of the

Abbreviations: PPE=personal protective equipment; PUI=person under investigation for COVID-19

Comparison by COVID-19 status divides patients from the COVID era only into COVID-19/PUI (patients with positive SARS-CoV-2 test, or persons under investigation due to clinical symptoms with SARS-CoV-2 test result pending) and Non-COVID-19 (patients without a COVID-19 diagnosis and not under investigation at the time of RRT activation). Data are presented as n (%) for categorical variables and mean ± standard deviation for continuous variables. χ 2 and Fisher's exact tests (categorical variables) and t-tests (continuous variables) were used to determine p-values for each comparison. Definition of terms: RRT=rapid response team. Other indication= uncontrolled hemorrhage, non-stroke neurological condition, hypoglycemia, fall, allergic reaction, pain, and abnormal laboratory results. NIV=non-invasive ventilation (including bag-valve mask ventilation and non-invasive positive pressure ventilation)

The authors would like to thank the many nurses, respiratory therapists, pharmacists, patient transporters, security personnel, advanced practice providers, physicians, hospital leaders, and others whose input and practice were critical to the design and implementation of the clinical emergencies team response to COVID-19 at the Hospital of the University of Pennsylvania.J o u r n a l P r e -p r o o f