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This article was written by Seife Yohannes, MD. Newly published research shows that a system to monitor and treat COVID patients’ respiratory health outside the ICU resulted in 27% fewer admissions, shorter stays, and lower risk of ventilator placement.
In the spring of 2020, COVID-19 was causing disease and death in Asia and Europe, and New York City hospitals and morgues were experiencing significant overcrowding. Knowing the virus would soon arrive in Washington, D.C.; we established an early warning system that quickly transformed MedStar Washington Hospital Center into a multi-floor Intensive Care Unit.
This allowed special response teams to care for critically ill patients with COVID-19 on the medical floors of the hospital, easing the strain on the ICU. We’ve recently published research in Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine that shows this system reduced ICU admissions, shortened length of stay in the ICU.
During “surges” in the COVID pandemic, when potent new strains circulated and many people were sickened, a tremendous burden was placed on all hospital staff and resources, particularly the ICU.
According to the U.S. Centers for Disease Control and Prevention, these conditions and ICU capacity were associated with excess deaths—not just for patients with COVID-19, but also those who needed care for other life-threatening illnesses. CDC data suggested that with ICU beds at 75% of capacity, an additional 12,000 deaths could be expected nationwide within two weeks, with more to follow. At 100% ICU capacity, 80,000 excess deaths could be expected two weeks later, and this was just the start.
At MedStar Health, dedicated teams worked to develop a system to help reduce stress in the ICU. Our multi-center, retrospective cohort study tells us that it worked as intended. While we mourn the loss of so to COVID-19, we know that the extraordinary efforts made throughout MedStar Health saved many lives.
Confronting new challenges by adapting systems.
In 2017, MedStar Health established an electronic early warning system for sepsis, the body’s response to complicated infection. When early COVID-19 patients began triggering this system, we realized it could help us understand when their breathing was worsening (hypoxemia and tachypnea) and respond with closer monitoring and treatment.
We called this system CEWS, for COVID Early Warning System. Developed by a multidisciplinary team of physicians, nurses, and advanced practice providers, our Chief Technology Officer programmed CEWS in the hospital’s electronic health record system within a week.
The CEWS system monitored patients’ vital signs more often—every four hours—including respiratory rate, heart rate, temperature, and white blood cell count. When the equipment was available, we used continuous pulse oximetry to monitor patients’ oxygen saturation.
At this time in the pandemic, before vaccines were available, each interaction with a patient was dangerous and limited. Our COVID-19 patients received around-the-clock monitoring and more interactions with rapid-response nurses and advanced practice providers than in most care settings.
The CEWS in-house protocol algorithm identified high-risk patients who needed additional bedside monitoring or treatment and evaluated whether they needed to be transferred to the ICU for a higher level of care.
Related reading: Managing Breathing Difficulties Associated With Long-COVID.
Policy changes to account for this new system meant that patients with hypoxemia could remain on the medical floors, receiving additional treatment to increase the amount of oxygen in their blood instead of being transferred to the ICU, where space was at a premium. Patients on our floors received intensive care while reserving the ICU for the most severe cases.
Study: CEWS reduced ICU admissions.
With the worst of the pandemic behind us and vaccines helping to limit sickness, we’ve been able to analyze the data to learn about the success of CEWS. We studied the impact of CEWS and our dedicated response team to identify and treat COVID-19 patients with worsening respiratory distress on the medical floors when ICU capacity was strained.
We found that this protocol resulted in significantly fewer ICU admissions among patients with moderate and severe hypoxia without needing more breathing assistance and more deaths. Knowing there is a link between ICU capacity and worse outcomes from COVID-19, the CEWS strategy proved effective at easing the ICU burden without compromising patient safety.
Our research also found that their length of stay was shorter when CEWS patients were admitted to the ICU. This was likely because their deteriorating breathing was identified earlier. In some cases, ICU patients who were not worsening could be transferred to CEWS floors, opening still more capacity.
Overall, we noted a 27% decrease in ICU admissions or mechanical breathing assistance. That meant fewer patients in the ICU, fewer intubation procedures, and fewer deaths.
While the COVID-19 pandemic has eased, this strategy could be beneficial if new strains or novel pathogens emerge.
Related reading: My Experience Working in the Emergency Room During COVID-19.
During COVID, people saved lives.
I am so proud of our work throughout the MedStar Health system and of our CEWS’s impact. It is gratifying to know our quick thinking, innovative teamwork, and system-wide resource sharing had a measurable impact on our patients. This was only possible due to the collaborative efforts and hard work of frontline providers, intensivists, ICU APPs, hospitalists, rapid response nurses, and floor nurses who make up our fantastic team.
I will forever be grateful to the colleagues who fought daily to save lives despite overwhelming challenges.
