When the first wave of coronavirus patients flooded New Jersey hospitals earlier this year, clinicians were heavily focused on ventilators. At the apex of the pandemic, one in four people hospitalized for COVID-19 needed these machines to breathe, and the state’s supplies were running short.
Six months later, the picture has changed dramatically. Ventilators are still critical for some patients — 10% of those hospitalized earlier this week depended on artificial respiration, according to state data — but clinicians now try to employ less invasive protocols first, like high-flow oxygen or repositioning patients to ease breathing, called “proning.”
“When the pandemic started, we intubated you at the drop of a hat,” said Dr. Lewis Nelson, who leads the emergency department at University Hospital in Newark, which was at the heart of the outbreak. Intubation generally requires the patient to be heavily sedated as a tube is then inserted into the windpipe and connected to the ventilator, which is calibrated to provide a specific oxygen concentration. The patient often requires a catheter to collect urine as well.
Maintaining delicate balance
“There’s a sweet spot” in balancing who needs to be intubated and who could benefit more from other treatments, said Nelson, who also chairs the emergency medicine department at Rutgers New Jersey Medical School. “You have to use a good amount of clinical judgment.”
The shift in pulmonary treatment is just one example of how inpatient care for COVID-19 has evolved in New Jersey since the virus first emerged publicly in March and began spreading, sickening tens of thousands. Nearly 210,000 residents have tested positive for the virus, including more than 14,400 who have died.
While clinical research remains limited, physicians said some evidence is beginning to emerge about what treatments work best for coronavirus patients. There are a few medications that appear to reduce the related symptoms, they said, and medical providers are better able to identify problems and predict the course of the disease. There is no cure for COVID-19 and the quest for a vaccine continues.
“We’re still not making decisions based on high-quality evidence,” Nelson said. “It’s much better than it was before, but it’s still limited.”
Dr. Gregory Breen, with Inspira Medical Group Pulmonology, said he feels a “palpable difference” in the clinical options available today, versus six months ago. “Its more tools and more confidence and more knowledge. All of which is leading to better outcomes for our patients,” he said.
Coronavirus patients are now far less likely to require critical care or be placed on ventilators, Breen said, and hospital stays are getting shorter than they were initially. National data suggests the mortality rate for acute-care patients has declined 40% to 50% since the pandemic’s start. Inspira has seen similar results, he said.
Dispelling the darkness
“You’re just seeing the world open up a little bit and seeing light shine into a previously dark place. But there’s a long way to go,” said Breen, who has offices in Mullica Hill and Woodbury. “Our patients are getting better and they are getting better with greater frequency,” he said, adding, “There’s still a ton of unknowns and a ton of challenges ahead.”
Inspira Health has also tapped into an existing outpatient-monitoring program to help guide the long-term recovery of COVID-19 patients with pulmonary issues. Using a device to measure the patient’s blood-oxygen level at home, which automatically reports data to a hospital team, clinicians have been able to discharge individuals sooner and still closely track their progress.
“It’s a complete shift,” Breen said of the protocol. “In my 20 years in practice that’s never happened before,” he said, noting that medical providers, government regulators and insurance companies worked together to allow these stable patients who still needed supplemental oxygen to be discharged sooner than they would historically. “In the past if you had pneumonia and were on oxygen, you didn’t go home,” he said.
Perhaps the biggest change in New Jersey is in the volume of COVID-19 patients at the state’s 71 acute-care hospitals. State statistics show that as the initial outbreak peaked in mid-April, more than 6,000 people were receiving inpatient treatment; one-third of these patients were in critical-care rooms and more than one in four were on a ventilator. As of Monday, hospitals were treating 445 coronavirus patients, with 29% in critical care and 10% on ventilators.
At times during the surge, multiple hospitals would be forced to temporarily suspend new admissions and divert ambulances to neighboring emergency departments, as coronavirus patients overwhelmed their bed or staff capacity. Several times officials shuttled ventilators from one facility to another to meet demand, and state and hospital leaders worked together to create a strategy to ration these machines and other scarce resources, should there not be enough for all patients. Shortages of nursing staff and personal protective equipment, or PPE — the masks, gowns and gloves designed to help stop the spread — were common in the early months.
Evolving COVID-19 treatments
“As one of the nation’s first hotspots, New Jersey hospitals and their clinicians helped write the playbook on treating patients with this novel virus. We moved from ventilators, to proning, through temporary detours like hydroxychloroquine, to some of the promising drug treatments like remdesivir and dexamethasone that we’re using today,” said Cathy Bennett, president and CEO of the New Jersey Hospital Association, which worked closely with the state Department of Health to coordinate acute-care resources.
Bennett said the NJHA hosted regular calls that enabled diverse clinicians — including doctors, nurses, respiratory therapists and pharmacists, among others — from across the state to learn from each other’s experiences. “The clinicians were extremely generous in sharing their knowledge, and these weekly calls became a forum that fostered evidence-informed practices that have advanced how we approach this novel virus — not only in New Jersey but across the country,” she said.
When it comes to pharmaceutical interventions, the National Institutes of Health updates its treatment guidelines regularly to help clinicians navigate a rising tide of public speculation about possible treatements. In recent months the panel recommended against the use of chloroquine or hydroxychloroquine — a drug touted by President Donald Trump early on — and certain monoclonal antibodies (sarilumab, tocilizumab and siltuximab), citing a lack of data on their efficacy and safety. In September, the group also opposed the use of convalescent plasma for the same reason, but encouraged people to participate in clinical trials.
The NIH panel did endorse the use of dexamethasone, a steroid that helps stop the overblown immune system reaction that occurs in some COVID-19 patients. Trump, who was diagnosed with the virus on Oct. 1 and hospitalized the following afternoon, received a previously untested cocktail of medications that included dexamethasone, experimental antibodies and remdesivir, which has been authorized for emergency use on coronavirus patients.
Some promising results
Inspira’s Breen said he’s seen promising results from both dexamethasone and remdesivir, two pharmaceuticals that were routine COVID-19 treatments early on. Nelson, at University Hospital, has also had some success with steroids, but is less sold on remdesivir.
“The data is poor,” Nelson said, “and it might be a waste of money. It’s definitely not a panacea. It’s not the Narcan of antiviral agents,” he added, referencing the brand name for naloxone, the highly effective opiate-overdose reversal agent.
While greater knowledge and treatment options have improved patient outcomes, health officials agree more research is needed to confirm the best-practice protocols for treating COVID-19 patients. They are also learning more about the long-term impacts of coronavirus infection, which can involve weeks or months of recovery at home. “It’s not a quick, rapid illness. It takes time,” Breen said.
At the same time, they are bracing for a second wave of the virus. “We do believe we’re going to have a resurgence. COVID has not just disappeared,” Nelson said.