This year we asked Karen S. Sibert, MD, who is a member of the Anesthesiology News editorial advisory board, to arrange a roundtable of experts in intensive care. Dr. Sibert, a clinical professor of anesthesiology and the director of communications at UCLA Health, enlisted the assistance of David W. Boldt, MD, a critical care anesthesiologist at Ronald Reagan UCLA Medical Center.
Together they wondered, “Is there any aspect of health care that didn’t change or evolve as a consequence of COVID–19?” They picked a group of intensive care experts and asked them a series of questions, enlisting comments on how their practices did—or didn’t—change over the course of the pandemic, and which of the changes they expect to be permanent. They found the answers to their questions to be surprisingly variable, but also fascinating and, overall, very hopeful.
Participants
 | Associate Professor Division Chief of Critical Care Medicine Department of Anesthesiology, Perioperative and Pain Medicine Department of Medicine—Palliative Care Section Stanford University Stanford, Calif. |
 | Professor of Anesthesiology Director, Multidisciplinary Critical Care Consultant, Department of Anesthesiology and Perioperative Medicine Mayo Clinic Rochester, Minn. |
 | Vice Chair: Quality, Safety and Critical Care Division Chief, Critical Care USC Department of Anesthesiology Keck School of Medicine of USC Los Angeles |
 | Professor of Clinical Anesthesiology Executive Vice Chair for Clinical Affairs Department of Anesthesiology Weill Cornell Medicine New York City |
 | Clinical Professor, Anesthesiology and Surgery Anesthesiology and Critical Care Medicine Department of Anesthesiology Ronald Reagan UCLA Medical Center Los Angeles |
 | Allen I. Hyman Professor of Critical Care Anesthesiology Chief, Division of Critical Care Medicine Medical Director, Surgical Intensive Care Unit Columbia University Irving Medical Center New York City |
 | Liver Transplant Anesthesiology, Critical Care Medicine Director, POCUS Program Ochsner Medical Center New Orleans Assistant Professor Ochsner Clinical School University of Queensland Queensland, Australia |
 | Fellow, Pulmonology and Critical Care Medicine University of Massachusetts Medical School Worcester, Massachusetts |
 | Associate Professor Department of Anesthesiology Division Chief, Critical Care Medicine Medical Director, Surgical Intensive Care Unit The University of Texas Medical Branch Galveston, Texas |
The participants reported no relevant financial disclosures.
Download the printer-friendly PDF version here.
- Has COVID-19 led to changes in ICU practice in terms of end-of-life care? Anecdotally, our impression is that fewer CPR codes are being run because ICU teams have become more proactive in terms of discussing plans and prognoses with families and are decreasing resuscitative attempts in futile cases. Has this been your experience?
Aslakson: From early in the COVID-19 pandemic, Stanford University Medical Center developed an interprofessional Critical Care Task Force (CCTF) that coordinated all aspects of critical care delivery during the COVID pandemic. The CCTF was a group of about 30 individuals, and included ICU nurses, ICU physicians, ER critical care physicians, respiratory therapists, pharmacists, ethicists, palliative care specialists and hospital administrative leaders. We convened hourly meetings one to three times a week, with the frequency of meetings depending on the volume of COVID patients at the hospital and the magnitude of the impact of those patients on regular ICU practices.
CPR is already ineffective in a majority of critically ill patients who code, and from early in the pandemic, we started to suspect that it was even more nonbeneficial in patients with severe COVID. We discussed this on the CCTF and, incorporating input from our colleagues in ethics and palliative care and working with our colleagues in the ER and the COVID floor wards, instigated more proactive code status discussions with COVID patients and their families, even before the patients might be critically ill and requiring ICU care.
Brown: Actually, I would not say that has been our experience. COVID reached us later than either coast so we had the advantage of appreciating the prognosis in these cases and our normal processes, in terms of addressing end-of-life care, were applied, and served us and our patients well.
Sara: The pandemic has had us all thinking about our mortality as well as offering some clarity to draw upon when prognosticating. Together, these trends have led to the involvement of palliative care teams earlier in the course of disease. Hopefully this trend is solidified and strengthened, as the palliative care teams have excellent resources for supporting patients and their families through times of critical illness. However, family belief systems often contradict our expert opinions, which is when I reflect on a mentor’s words: “We’re not here to change the local culture.” COVID has not changed my preferred course of action, which is to honor the patient’s values on a “meaningful” life, no matter my opinion on the outcome.
Sibert: There are fewer codes, and there is more proactive discussion, but there is also more willingness to speak openly with families about poor outcomes. Especially in a teaching environment, more learners have been exposed to more mortality, inevitably changing their views on the service of providers treating morbid patients. Withholding resuscitation remains beyond the general reckoning, regardless of individual opinion on the futility of the treatment for the patient’s long-term health.
- The practice of proning patients with respiratory failure: Is it more common now than it was before COVID-19? What about “self-proning”? Is this a concept that is likely to continue as standard care in our management of acute respiratory distress syndrome (ARDS) due to all causes?
Aslakson: We actively used proning before COVID for our severe ARDS patients. During the COVID pandemic, we had more of these severe ARDS patients, and thus developed coordinated proning protocols and teams so that, practically, we could support the proning needs of this larger number of patients.
Brown: Proning certainly has a place in the management of refractory hypoxemia related to COVID or other etiologies. What I think COVID has done is to increase the frequency of use and improve the processes associated with the therapy.
Moitra: Compared to our first surge, we observed a lower threshold to prone our patients during the second surge. This lifesaving maneuver had become more familiar and the resources to prone patients had increased. Proning was part of the standard of care for management of severe ARDS before the pandemic, and former barriers to its implementation have been removed. I suspect that the number of patients with severe ARDS who will be proned will increase.
Sara: Proning for ARDS has been gaining favor for years and has been placed in the spotlight through the pandemic. The trials on proning, like PRON-COVID (The Prone Position in COVID-19 Affected Patients; ClinicalTrials.gov Identifier: NCT04365959), should shed more light on outcomes, but for now I see proning as a low-risk, high-reward tool in our limited armamentarium against ARDS that gives the body a chance to recover with improved oxygenation.
I think proning is seen more favorably now than prepandemic and will continue to be implemented with increased frequency. Moreover, patients who successfully proned showed improved oxygenation and, if awake, had reduced shortness of breath—an observation that was almost universal. Patients who were able to self-prone for ample time felt more encouraged because they were being proactive and could see a positive outcome from their ICU stay. The influence of patient motivation during times of perceived helplessness cannot be understated.
- In the early months of the COVID pandemic, we attempted to intubate patients early and proactively. Then that practice completely reversed. Do you think that we will continue to have a higher threshold before we decide to intubate patients over the longer term? Or does this trend apply only to patients with COVID?
Dhillon: I really look forward to seeing the data on early versus late intubation. Though our practice changed over the course of the epidemic, to a more delayed intubation, our mortality also increased in the ICU. Of course, this is complicated to tease out just from anecdotal experience, in that we may have been shifting toward sicker patients. Unfortunately, the decision to delay intubation was initially made because we felt it might be safer, and many patients avoided intubation altogether, with patience and high-flow oxygen. At the peak, it was also for us a question of resource utilization. I have personally not changed my threshold for intubation for non-COVID patients and am still on the fence as to what to do with a COVID patient.
Meltzer: The practice of early intubation certainly reversed itself as the pandemic continued. The myriad reasons for this change involved practitioner comfort with donning and doffing PPE [personal protective equipment], vaccination rates, as well as seeing poor outcomes with those who were intubated. COVID was very instructive as to what criteria clinicians should be using for intubation. We try in COVID patients—and all patients suffering from respiratory failure—to prevent intubation with noninvasive methods, such as high-flow oxygen, BiPAP (bilevel positive airway pressure) and lung expansion modalities.
As opposed to traditional triggers such as hypoxemia, we are moving toward more meaningful things such as dyspnea, work of breathing, and the end-organ dysfunction resulting from hypoxemia or hypercarbia, such as encephalopathy, renal dysfunction or metabolic acidosis. The happy hypoxia of COVID may be responsible for this teaching point.
Moitra: I think we will be more cautious about significant changes in practice without robust evidence. Resources for and familiarity with high-flow nasal cannula oxygen delivery and noninvasive ventilation have increased in non–critical care settings. Over the long-term, thresholds to intubate may increase.
- Has your practice regarding sedation and muscle relaxation for intubated patients changed at all since the start of the pandemic?
Brown: I would not say that the practice changed, but what I would say is that some patients were very difficult to sedate and paralyze. The associated side effects are as you would expect, but seemed to be seen more frequently and of increased severity.
Meltzer: The greatest trend in critical care over the last decade has been to do less and go back to the basics. For example, use less sedation and have your patient be more awake and use less invasive monitoring—for example, our reduction in the use of pulmonary artery catheters, central lines and Foley catheters. Get patients out of bed and ambulatory despite their level of critical illness. We have had much greater family involvement around the clock in the ICU. COVID turned all of these progressive practices on their collective ear. Patients required massive doses of sedatives to achieve lung-protective ventilation, ventilator synchrony, or in the case of a patient on ECMO (extracorporeal membrane oxygenation), circuit “synchrony.” We didn’t allow patients with COVID to ambulate freely in the ICU until they were deemed “COVID recovered.” We didn’t allow family visitation. These COVID-based practices went against the grain of modern, progressive ICU care, and this was very challenging for all of the staff caring for this population during the pandemic.
Teegarden: My sedation and muscle relaxation practice has not significantly changed due to the pandemic. I aim for a sedation plane that allows for optimal patient comfort that ideally maximizes engagement with clinical therapies and allows for efficient weaning from mechanical ventilation.
- During the worst of the pandemic, new therapies sometimes were tried before they could be rigorously evaluated in controlled trials. Do you think that attitudes have changed regarding the importance of robust medical research before the implementation of a new treatment concept in dire cases? How has your practice changed, if at all?
Aslakson: Throughout the COVID pandemic, we found the pace and evolution of new information to be a challenge and particularly relied on our CCTF to help with dictating what was going to be our practice at Stanford. The CCTF met one to three times a week so we could respond quickly to information as it emerged. Whenever there was a new study, we would discuss it on the CCTF. We also would invite related specialists to present and/or provide input on the topic, if needed.
For example, our infectious disease colleagues presented at multiple CCTF meetings and worked closely with our CCTF pharmacists as we made decisions about what would be our practice around COVID-related medications, such as remdesivir [Veklury, Gilead], dexamethasone or tocilizumab [Actemra, Genentech]. As the CCTF was interprofessional, we also had key stakeholder input for all decisions; for example, our respiratory therapist team members were deeply involved in any decisions related to different types of noninvasive positive pressure ventilation, high-flow nasal cannula or intubation protocols for COVID patients.
As a committee, we would make a decision, implement the decision, and revisit the decision as new data might emerge. We also had a real-time, COVID-specific website that displayed all our COVID-related protocols and resources, which was readily available for other front-line staff, particularly house staff, nursing and respiratory therapy.
Brown: Our practice really did not fundamentally change. We focused on ensuring we were providing consistent, evidence-based care. The Mayo Clinic was also very active in clinical trials (for example, the national convalescent plasma program was coordinated by a Mayo anesthesiologist). Each of our COVID patients were evaluated by a multidisciplinary investigative team which directed investigative therapies in a transparent and equitable manner. COVID has shown the value of clinical trials in evaluating novel therapies and the need to rapidly adapt practice as new information is generated.
Dhillon: From a purely medical standpoint, the first few months of the pandemic were enlightening. It reiterated the value of an observant bedside clinician and rapid cycle process improvement—medicine perhaps as it used to be decades ago … . In speaking with infectious disease colleagues who had been part of the HIV epidemic in its early years, they likened the environment of learning and experimentation to that moment. I hope that this experience reiterates and reinvigorates the value of an astute bedside clinician, who sometimes in the current ethos of medicine is undervalued.
Ivascu: The pandemic isolated a lot of people across the world but really united the critical care community. Locally, nationally and internationally, our unified attention to this disease facilitated an unprecedented sharing of experience and information in real time. I believe that we should always strive for a rigorous analysis of treatment strategies, but practically speaking, we can’t always wait for a randomized controlled trial. I think that we learned the importance of making the best decision we can in the moment and constantly reevaluating to pivot our treatment algorithms when controlled trial data can be gathered.
Sibert: COVID exposed global weaknesses in the relationship between medicine and science. Nationally, institutional authority grew to enforce treatment guidelines, isolation practices and staff monitoring largely without continuous critical review. While pharmaceutical COVID therapies have come and gone with the published evidence, aggressive safety measures, appropriately adopted early in the pandemic, have become entrenched and unresponsive to new data.
- Human connections have been severely challenged in 2020 and 2021. Families were unable to bid farewell to dying patients. Staff members were hidden behind PPE. Will we ever go back to prepandemic levels of patient and family personal contact in the ICU? What lessons have we learned that we will carry into the future?
Aslakson: The lack of involvement of families at the bedside of critically ill patients was absolutely one of the hardest parts of the pandemic, not only for patients and family members but also the interprofessional ICU team. It affected not only critically ill COVID patients but all of our ICU patients who, even if they did not have COVID, were unable to have their family present. Not having family at the bedside to support their loved ones and to communicate and work with the ICU team was akin to trying to juggle with one hand tied behind your back; it made everything just so much harder. Lack of family presence led to significant moral distress to the ICU clinician team as they agonized over watching, and having to enforce, family separations during these most difficult and tragic of medical situations.
Family members are a core part of the team caring for a critically ill patient, and our ability to provide optimal care is substantially hampered by their absence. We knew this before the COVID pandemic; the absence of families during the pandemic just reinforced that knowledge. I absolutely believe that we will go back to “pre” levels of family involvement in the ICU because we already knew, even before the pandemic, that such family involvement is an essential, core component of good ICU care.
Brown: COVID demonstrated the value of human connections with our patients as well as our families, friends and colleagues. It will be interesting to observe the balance between these connections and public health as we emerge from the pandemic. I think society is still evolving in this assessment.
Dhillon: The impact of lack of family contact haunted my practice and negatively affected my ability to care for my patients, and also for my own emotional healing and being able to come back to work the next morning. The connection and human touch with a family member of a dying patient is a selfish way for me to heal what is always a wound. We allowed families of end-of-life patients to visit first; it was very awkward and uncomfortable to watch them in their grief with my arms folded across my chest. So, I must admit I very quickly started a process of asking them if they were OK with being hugged, and it was very rare anyone said no, and the moment allowed both sides to feel human in an environment that broke all of humanity. I have no doubt we will go back to prepandemic levels of contact, as that connection is a huge part of the process of healing—not just at the end of life.
Ivascu: I am hopeful that we will cautiously resume some pre-COVID practices. We have a new appreciation about the risk for disease spread and I think we have a renewed commitment to proper use of PPE and appropriate isolation practices. It is our privilege to be a part of people’s lives when they are at their most vulnerable. Sometimes the greatest service we can provide is holding their hand when their loved ones cannot. Like many places, we utilized communication teams to offload a duty from the heavily burdened ICU teams. I was surprised that families were very responsive to these updates, even if they were not from the primary team. Going forward, we need to find ways to maintain frequent communication with family members, whether separated by visitation restrictions, distance, or simply the ability to leave their personal work or home duties to be at the bedside.
Meltzer: We must, and have already started to, go back to our prepandemic levels of human contact in the ICU. The thought that we were letting people die alone without their families changed our practice, even during the pandemic. We pivoted and realized our errors and started to allow limited visitation to COVID-positive patients at the end of life. We are currently moving back to our prior practices of 24/7 family visitation and involvement. We have learned much over the years about how to liberate our patients with critical illness by achieving an improved condition with nutrition, exercise, mobilization and prevention of complications, so we must return to prepandemic practices—and, oh yes, get vaccinated!
Moitra: The separation of patients from families contributed to a profound sense of loss for intensivists who find joy in human connections. The mental toll of patients who died, separated from their families, was real. Our challenge is to find safe ways of ensuring the human connection, independent of privilege and advocacy, to retain our sense of humanity at the time of death.
Sara: I think we will be able to get back to prepandemic levels of patient and family contact in the ICU, especially as rates of new infections decrease. However, patients, families and hospital staff need to be ready for visitation rules to swing back and forth as new waves make their way around the world. That being said, the pandemic offered us opportunities to get as creative as possible with patient and family contact, and technological advances such as video calls have changed the way we can provide care in general, as well as closure for families who cannot make it to the bedside. I am excited to see the ways technology will be implemented in the future for family communication, even for COVID-negative patients.
Teegarden: As one who strongly advocates for the presence and active participation of families throughout one’s ICU stay, it has been especially hard to see the impact of pandemic-induced visitation restrictions on our patients, their families and staff. COVID policy changes started just as our surgical ICU had begun an IRB [institutional review board]-approved project aimed at better engaging with our [patients’] families, part of a multicenter “Family Engagement Collaborative” led by Dr. David Hwang and the Society of Critical Care Medicine. While it feels like a glacial pace, we are slowly returning to prepandemic levels of patient and family contact in the ICU, and with that, the hope to reimplement projects that engage and welcome our ICU families.
- Is there anything else that you would like the general audience of anesthesiologists to know about ICU care today? Do you have a “pet peeve” in terms of receiving patients from the OR—what would you like to see done differently by OR anesthesiologists?
Dhillon: I find myself reflecting a lot on the aftermath of the pandemic on my colleagues across all front-line providers. In the fight-and-flight of the pandemic, we were pushed forward by our collective activity and mission. Today, I hear from so many that they feel numb, unable to really engage, unsure of what they want from their careers, and though they come to work every day, no amount of sleep, exercise or self-care seems enough. I feel for our trainees and junior attendings who took the brunt of this very strange year. It feels as if we are Vietnam or Korean War veterans who are now trying to reintegrate into our old lives. Should we as health systems be looking at reintegration programs as the military does? Should this form of PTSD [post-traumatic stress disorder]/second victim become an increased part of our research in the upcoming years? How has this impacted our most vulnerable—the trainees and junior attendings? I don’t have any answers, but I have anxiety about who will be standing next to me in the ICU in upcoming years.
Teegarden: My personal pet peeve in receiving patients from the OR is the trend to give large doses of paralytics prior to transport (“roc for the road”). This delays my ability to turn off sedation, assess for extubation readiness or transition to a lighter depth of sedation. I understand the practice and don’t want lines or tubes being inadvertently removed during transport but suggest providing a smaller dose and reversing at handoff in the ICU.
Ivascu: Recovery from surgery starts in the OR, or even before. ICU care today has shifted from bed rest and deep sedation to early mobilization and alimentation. The OR team sets the patient up for success by attention to multimodal analgesia, minimizing opioids, temperature management and reversal of neuromuscular blockade. Sometimes even the smallest things done in the OR can have a big impact later!
Concluding comments, by David Boldt:
There have been many changes seen and lessons learned by health care providers during the pandemic, and intensivists were perhaps one of the groups of clinicians most drastically affected. Some are here to stay, such as the increased use of proning in ARDS, while others, such as our threshold for intubation or our use of sedatives and muscle relaxants, will likely return to a level of prepandemic practice patterns. Through these changes we have grown, indeed, and we have seen our beliefs in the importance of rigorous and thorough scientific research and the value and necessity of human connection in our daily work strengthened.
One thing is for sure, however: The forced lack of human connection affected all in a negative way, and we will undoubtedly welcome this critical aspect of our care back to our daily practice with open arms, literally.
Copyright © 2021 McMahon Publishing, 545 West 45th Street, New York, NY 10036. Printed in the USA. All rights reserved, including the right of reproduction, in whole or in part, in any form.
Download to read this article in PDF document:
Intensive Care During the COVID-19 Pandemic: A Roundtable
Please log in to post a comment