Northwestern Medicine Leaders on COVID-19 and ICU Care
GR Scott Budinger, MD, chief of the Division of Pulmonary and Critical Care Medicine, and Ankit Bharat, MD, chief of Thoracic Surgery, share how the Northwestern Medicine team is handling an influx of and caring for patients with severe COVID-19 illness in the ICU. They discuss when ventilators should be used and alternative approaches the Northwestern Medicine team is utilizing, including extracorporeal membrane oxygenation (ECMO), prone positioning and verticalization therapy, to provide the next level of care when a patient does not respond to ventilation.
Featured Speakers:
Ankit Bharat, MD is the Chief of Thoracic Surgery.
GR Scott Budinger, MD | Ankit Bharat, MD
GR Scott Budinger, MD is the Chief of the Division of Pulmonary and Critical Care Medicine.Ankit Bharat, MD is the Chief of Thoracic Surgery.
Transcription:
Northwestern Medicine Leaders on COVID-19 and ICU Care
Melanie Cole (Host): This is the Northwestern Medicine podcast on COVID-19 dated May 7, 2020.
Welcome to Better Edge. A Northwestern Medicine podcast for physicians. I’m Melanie Cole and today, Dr. G. R. Scott Budinger Chief of the Division of Pulmonary and Critical Care Medicine and Dr. Ankit Bharat, Chief of Thoracic Surgery share with us how the Northwestern Medicine team is handling an influx of and caring for patients with severe COVID-19 in the ICU. Dr. Bharat, how is Northwestern Medicine handling this influx of COVID-19 cases?
Ankit Bharat, MD (Guest): Even before we got our first patient, there was a lot of planning that went behind preparing us for this influx of COVID-19 patients. So, we made a significant amount of changes in our facilities for example, we’ve created COVID-19 units for patients who require both ICU level of care as well as those who require hospitalization but not in the ICU. Now these units are physically separated from the other units where the non-COVID patients are kept. And that is done to maintain the safety of our non-COVID patients.
As far as the patient care is concerned, we created multidisciplinary teams that include the top specialists from all the relevant specialties including infectious disease, pulmonary medicine, thoracic surgery, the ICU doctors to really form these teams and most effectively take care of these patients. We made sure that our patients had access to all the clinical trials for COVID-19 and also partnered with the industries to make sure that our patients can get some of the medications on a compassionate base use.
Host: Dr. Budinger, when is your team initiating care with a ventilator for a patient with COVID-19?
G. R. Scott Budinger, MD (Guest): In some patients, the virus attacks the lower airways or the alveoli, the small airways – small sacs that exchange gas in the lungs. In those patients, oxygen levels will fall and when we see a lower oxygen level in the emergency department, we often will admit those patients to the hospital for supplemental oxygen therapy. Because COVID pneumonia can progress very, very quickly, we watch very, very closely those oxygen levels and when they get sufficiently low in patients with severe disease, we institute mechanical ventilation. There are some advanced therapies that we can use like high flow nasal cannula treatments that can stave off intubation in a few patients. But in many of the patients with rapidly progressive disease, we need to put them on a ventilator relatively early in their course to prevent them developing complications from that low oxygen level.
Host: Dr. Bharat, what are some alternative care techniques you are using for patients with COVID-19?
Dr. Bharat: We use ECMO for patients who have been placed on the mechanical ventilator but that is not enough to support their oxygen levels and the gas exchange. So, it’s used as really the next level of care after these patients have been placed on the mechanical ventilator and are not responding to it.
Dr. Budinger: Currently, we are using ECMO as a therapy for patients that have failed all of the standard things, we do for patients with COVID-19 pneumonia. That includes putting them on the ventilator, that includes adjusting their ventilator to be optimized for their disease. That includes prone positioning where we will actually ventilate patients on their stomach for some periods of time and if all of those things don’t work, then we will consider ECMO as a way to intervene and actually provide surrogate gas exchange through a machine essentially until the patient’s lungs have time to recover. We are very interested however, in whether ECMO might be used earlier in the course of the disease as a way to substitute for mechanical ventilation and maybe prevent some of the complications of mechanical ventilation that we see in some of the patients.
Dr. Bharat: The same concept as proning also applies to another type of treatment called verticalization therapy. In that, we actually have the patient stand up on the bed while the patient is on the ventilator or on the ECMO device. The patient is securely strapped to the bed and we make the patient stand up and by doing so, we can actually accomplish the same goals as the proning does and in select patients, it’s much safer and it’s less resource intensive than proning.
Host: Dr. Budinger, what is your guiding principle regarding treatments you are using for patients with COVID-19?
Dr. Budinger: At Northwestern, our guiding principle in caring for these patients has been that they are patients first and they are patients like any other patients and will benefit from treatments that we know work. So, we have gone to extraordinary lengths to make sure that we’re able to provide the usual suite of diagnostic tests, diagnostic therapies and treatments that are available to patients throughout our intensive care units. That involves strategies to protect our healthcare workers as they enter the rooms of these patients and care for them. But it also allows us to provide a very high level of ICU supportive care.
Dr. Bharat: So, at Northwestern, we are participating in all the clinical trials that are out there to explore the efficacy of different treatment options. We have partnered with the NIH as well as the industry to make sure all our patients get access to those trials. We are exploring some drugs including remdesivir which is quite effective for Ebola virus. We are also using some immune modulators specifically blocking what we call IL6 to control the cytokine storm that happens in the disease process and then we are also using other medications like hydroxychloroquine and azithromycin as part of the trials.
Host: Dr. Bharat, tell us about the measures Northwestern Medicine is taking to keep patients and caregivers safe.
Dr. Bharat: A number of steps have been made to ensure the safety of the caregivers that have included adequate access and training of the caregivers and the staff to use the personal protective equipment and the right personal protective equipment for individual patients. We have also now adopted a policy of universal precautions to basically assume that every patient may be at risk and we use the appropriate equipment for that purpose and then finally, we have tried to reduce any redundancy in patient contact. So, for example, when we round on these patients daily, we only have one person go in and examine the patient rather than the entire team. And that person then comes out of the room and then reports their findings to the rest of the team. So, by reducing the number of patient contacts we can reduce the spread and safety and improve the safety of the caregivers.
Dr. Budinger: Protecting the health of our workforce is a primary priority at Northwestern Medicine. We cannot take care of our sick patients if we can’t take care of ourselves. We have developed protocols within our COVID intensive care units for gowning, putting on and taking off these personal protective equipment as we go into the rooms of these patients. Our engineering team has been outstanding in taking some of our intensive care units, several of them actually and making them into negative air flow rooms. Our procurement specialists have done an outstanding job in making sure that we have adequate PPE to meet this challenge.
Host: Dr. Bharat what can providers tell their patients to do to help themselves at this time?
Dr. Bharat: During this pandemic, and even when the pandemic is over, I would love and desire for everybody to really be mindful of their lung health and take precautions to protect themselves and their family as well as the community from viruses such as COVID-19. And that includes taking personal responsibility from identifying yourself if you have any illness and making sure that you take all the precautions to avoid the transmission to other people but also protecting yourself and people at work or in the community have symptoms of respiratory illness. That’s the only way to curtail the spread of this disease and potentially other viruses that we may see in the future.
Host: Dr. Budinger, are there any other concerns that you have at this time?
Dr. Budinger: COVID-19 is not going to go away. This is something that we will probably be dealing with until we have an effective vaccine. The clock is ticking down. But we’re not there yet. The most important thing to know is that if the healthcare system is not overwhelmed, we can take care of these patients, we can take care of them well and we can get them better.
Host: Thank you both so much for great information. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on COVID-19, please visit our website at www.nm.org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.
Northwestern Medicine Leaders on COVID-19 and ICU Care
Melanie Cole (Host): This is the Northwestern Medicine podcast on COVID-19 dated May 7, 2020.
Welcome to Better Edge. A Northwestern Medicine podcast for physicians. I’m Melanie Cole and today, Dr. G. R. Scott Budinger Chief of the Division of Pulmonary and Critical Care Medicine and Dr. Ankit Bharat, Chief of Thoracic Surgery share with us how the Northwestern Medicine team is handling an influx of and caring for patients with severe COVID-19 in the ICU. Dr. Bharat, how is Northwestern Medicine handling this influx of COVID-19 cases?
Ankit Bharat, MD (Guest): Even before we got our first patient, there was a lot of planning that went behind preparing us for this influx of COVID-19 patients. So, we made a significant amount of changes in our facilities for example, we’ve created COVID-19 units for patients who require both ICU level of care as well as those who require hospitalization but not in the ICU. Now these units are physically separated from the other units where the non-COVID patients are kept. And that is done to maintain the safety of our non-COVID patients.
As far as the patient care is concerned, we created multidisciplinary teams that include the top specialists from all the relevant specialties including infectious disease, pulmonary medicine, thoracic surgery, the ICU doctors to really form these teams and most effectively take care of these patients. We made sure that our patients had access to all the clinical trials for COVID-19 and also partnered with the industries to make sure that our patients can get some of the medications on a compassionate base use.
Host: Dr. Budinger, when is your team initiating care with a ventilator for a patient with COVID-19?
G. R. Scott Budinger, MD (Guest): In some patients, the virus attacks the lower airways or the alveoli, the small airways – small sacs that exchange gas in the lungs. In those patients, oxygen levels will fall and when we see a lower oxygen level in the emergency department, we often will admit those patients to the hospital for supplemental oxygen therapy. Because COVID pneumonia can progress very, very quickly, we watch very, very closely those oxygen levels and when they get sufficiently low in patients with severe disease, we institute mechanical ventilation. There are some advanced therapies that we can use like high flow nasal cannula treatments that can stave off intubation in a few patients. But in many of the patients with rapidly progressive disease, we need to put them on a ventilator relatively early in their course to prevent them developing complications from that low oxygen level.
Host: Dr. Bharat, what are some alternative care techniques you are using for patients with COVID-19?
Dr. Bharat: We use ECMO for patients who have been placed on the mechanical ventilator but that is not enough to support their oxygen levels and the gas exchange. So, it’s used as really the next level of care after these patients have been placed on the mechanical ventilator and are not responding to it.
Dr. Budinger: Currently, we are using ECMO as a therapy for patients that have failed all of the standard things, we do for patients with COVID-19 pneumonia. That includes putting them on the ventilator, that includes adjusting their ventilator to be optimized for their disease. That includes prone positioning where we will actually ventilate patients on their stomach for some periods of time and if all of those things don’t work, then we will consider ECMO as a way to intervene and actually provide surrogate gas exchange through a machine essentially until the patient’s lungs have time to recover. We are very interested however, in whether ECMO might be used earlier in the course of the disease as a way to substitute for mechanical ventilation and maybe prevent some of the complications of mechanical ventilation that we see in some of the patients.
Dr. Bharat: The same concept as proning also applies to another type of treatment called verticalization therapy. In that, we actually have the patient stand up on the bed while the patient is on the ventilator or on the ECMO device. The patient is securely strapped to the bed and we make the patient stand up and by doing so, we can actually accomplish the same goals as the proning does and in select patients, it’s much safer and it’s less resource intensive than proning.
Host: Dr. Budinger, what is your guiding principle regarding treatments you are using for patients with COVID-19?
Dr. Budinger: At Northwestern, our guiding principle in caring for these patients has been that they are patients first and they are patients like any other patients and will benefit from treatments that we know work. So, we have gone to extraordinary lengths to make sure that we’re able to provide the usual suite of diagnostic tests, diagnostic therapies and treatments that are available to patients throughout our intensive care units. That involves strategies to protect our healthcare workers as they enter the rooms of these patients and care for them. But it also allows us to provide a very high level of ICU supportive care.
Dr. Bharat: So, at Northwestern, we are participating in all the clinical trials that are out there to explore the efficacy of different treatment options. We have partnered with the NIH as well as the industry to make sure all our patients get access to those trials. We are exploring some drugs including remdesivir which is quite effective for Ebola virus. We are also using some immune modulators specifically blocking what we call IL6 to control the cytokine storm that happens in the disease process and then we are also using other medications like hydroxychloroquine and azithromycin as part of the trials.
Host: Dr. Bharat, tell us about the measures Northwestern Medicine is taking to keep patients and caregivers safe.
Dr. Bharat: A number of steps have been made to ensure the safety of the caregivers that have included adequate access and training of the caregivers and the staff to use the personal protective equipment and the right personal protective equipment for individual patients. We have also now adopted a policy of universal precautions to basically assume that every patient may be at risk and we use the appropriate equipment for that purpose and then finally, we have tried to reduce any redundancy in patient contact. So, for example, when we round on these patients daily, we only have one person go in and examine the patient rather than the entire team. And that person then comes out of the room and then reports their findings to the rest of the team. So, by reducing the number of patient contacts we can reduce the spread and safety and improve the safety of the caregivers.
Dr. Budinger: Protecting the health of our workforce is a primary priority at Northwestern Medicine. We cannot take care of our sick patients if we can’t take care of ourselves. We have developed protocols within our COVID intensive care units for gowning, putting on and taking off these personal protective equipment as we go into the rooms of these patients. Our engineering team has been outstanding in taking some of our intensive care units, several of them actually and making them into negative air flow rooms. Our procurement specialists have done an outstanding job in making sure that we have adequate PPE to meet this challenge.
Host: Dr. Bharat what can providers tell their patients to do to help themselves at this time?
Dr. Bharat: During this pandemic, and even when the pandemic is over, I would love and desire for everybody to really be mindful of their lung health and take precautions to protect themselves and their family as well as the community from viruses such as COVID-19. And that includes taking personal responsibility from identifying yourself if you have any illness and making sure that you take all the precautions to avoid the transmission to other people but also protecting yourself and people at work or in the community have symptoms of respiratory illness. That’s the only way to curtail the spread of this disease and potentially other viruses that we may see in the future.
Host: Dr. Budinger, are there any other concerns that you have at this time?
Dr. Budinger: COVID-19 is not going to go away. This is something that we will probably be dealing with until we have an effective vaccine. The clock is ticking down. But we’re not there yet. The most important thing to know is that if the healthcare system is not overwhelmed, we can take care of these patients, we can take care of them well and we can get them better.
Host: Thank you both so much for great information. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on COVID-19, please visit our website at www.nm.org to get connected with one of our providers. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I’m Melanie Cole.