COVID-19: Expert Review of Relevant and Emerging Literature

COVID-19: Expert Reviews of Relevant and Emerging Literature2020-05-29T11:40:37-04:00

This article reports on the Ohio Hospital Association’s adoption of new guidance for allocating scarce resources during a public health emergency, including recommending the use of a triage committee rather than bedside personnel to make allocation decisions. The guidance also addresses other resource allocation strategies, such as modifications to licensure requirements to increase available health care workforce and expansion of telehealth and community paramedicine to alleviate surge.

The Ohio Hospital Association guidelines are explicitly informed by the work of the Institute of Medicine’s 2009 report on crisis standards of care, and an association spokesperson also indicated that the plan was developed using a variety of other federal and state templates on resource allocation.

The full Ohio Hospital Association report is available here. It cites as key ethical considerations fairness, duty to care, duty to steward resources, transparency, consistency, proportionality, and accountability. The report suggests that hospitals utilize a triage team composed of representatives from medical staff, nursing, and ethics be responsible for collecting scoring data, calculating triage scores, identifying patient who quality or no longer quality for scarce resources, and maintaining appropriate documentation of triage decisions and rationale. The report notes that hospitals will develop their own specific approaches, but recommends that an objective tool removes bedside providers from the decision and provides a fair and consistent method for allocation.

The report recommends the following exclusion criteria for critical care intervention:

  • Patients unlikely to benefit from critical care intervention
  • Patients with low probability of survival despite care
  • Patients requiring resources that cannot be provided
  • Patients with poor prognosis and high likelihood of death due to underlying illness
  • SOFA score equal to or greater than 11
  • Unwitnessed and/or recurrent cardiac arrest
  • Severe trauma with predicted mortality of >90%
  • Severe burns with predicted mortality of >90%
  • Incurable metastatic malignant disease
  • Advanced and irreversible immune-compromised condition
  • Known or previously documented end-state organ failure (with specific criteria)
  • Patient preference to be excluded.

This essay from Joseph J. Fins, one of the authors of New York’s 2015 guidelines on ventilator allocation during a public health emergency, contends that the Task Force’s guidelines should not be interpreted to authorize the commandeering of ventilators used by chronic care patients in response to resource scarcity.

The author responds to questions and critiques of the 2015 guidelines and an earlier draft from 2009 that posed the question of whether chronic care patients’ ventilators would be removed and reallocation in the event crisis standards of care triage protocols were implemented. As the author notes, the final 2015 guidelines explicitly distinguish between acute care facilities and chronic care facilities regarding application of triage protocols. The author explains that, under the guidelines, a chronic care patient who is ventilator-dependent and arrives at an acute care facility will be treated the same as any other patient in terms of application of relevant allocation criteria. He further clarifies that, in his interpretation, this means that a chronic care patient may or may not be allocated a hospital ventilator (which are typically more sophisticated than those used in chronic care facilities), but would not be at risk of losing access to the chronic care ventilator the patient was already using.

This article reports on new guidelines from Massachusetts health officials for potential rationing of ventilators in the event COVID-19 case surge overwhelms available supply.

According to the article, the guidance uses an 8-point scoring system based on a patient’s likelihood of surviving to discharge and likelihood of long-term survival. The system also that gives preference to medical personnel, women further along in pregnancy, and younger patients (when scores are otherwise equal).

The guidelines are based on those developed at the University of Pittsburgh and adopted by Pennsylvania. The guidelines are advisory and not mandatory, and some hospital systems have developed their own policies, some of which are consistent with the Massachusetts and Pennsylvania guidelines and others which differ on certain points, such as priority for health care personnel or consideration of long-term survival.

Some state rationing plans, including Pennsylvania’s, have been subject to civil rights complaints from advocates for persons with disabilities, who argue the plans illegally disadvantage persons with pre-existing disabilities based on biased assessments and generalizations about life expectancy or quality of life of persons with disabilities.

This editorial highlights the importance of disseminating information graphically via social media for rapid uptake by health care providers.

Individuals are facing a challenge of transferring knowledge about current best practices to people who need it most – frontline health care workers. Preventing infection and promoting psychological well-being is essential during a pandemic, especially when negative effects can be exacerbated by uncertainty. In order to disseminate information at a rate equal to or quicker than the spread of the virus itself, free open access education materials disseminated via appropriate social media channels should be utilized. One effective way to transmit this information is through well-designed infographics that are clear, concise, and practical. This communication tool has been shown to increase message retention. Successful dissemination will be affected by existing reputation of the disseminator, quality of infographic images and content, and rapid dissemination by social media platforms with professional participants.

Social distancing measures to address the U.S. COVID-19 epidemic may have significant health, social, and economic impacts. This study estimates the mean change in state-level COVID-19 epidemic growth before versus after the implementation of statewide social distancing measures in the United States.

Using interrupted time-series analysis, the authors examine the impact of time in relation to implementation of the first statewide social distancing measure on COVID-19 growth rate, which was calculated as the log of daily COVID-19 cases minus the log of daily COVID-19 cases on the prior day. The pre-implementation period began 14 days prior to implementation and included up to 3 days after implementation to account for incubation. Post-implementation began 4 days after, up to and including March 30.

The found that all states applied some form of statewide social distancing between March 10-27. The mean daily COVID-19 growth rate decreased beginning four days after implementation of the first statewide social distancing measures, by an additional 0.8% per day; 95% CI, -1.4% to -0.2%; P=0.002).

This reduction corresponds to an increase in doubling time of the epidemic from 3.3 days (before) to 5.0 days (at 14 days after implementation).

They conclude that statewide social distancing measures were associated with a decrease in U.S. COVID-19 epidemic growth. Based on the size of the epidemic at the time of implementation in each state, social distancing measures were associated with a decrease of 3,090 cases at 7 days, and 68,255 cases at 14 days, after implementation.

This paper focuses on two scalable and readily available methods of mass reporting of COVID-19 cases in real time to fill in important gaps in the operational reporting of this pandemic.

To respond to COVID-19, many countries are using a combination of containment and mitigation activities with the goal of attenuating community spread. Thus current information available to the public may be a gross under-reporting of the current epidemic and do not allow for the strategies and scale of resource re-allocation needed to provide supportive care to those becoming critically ill.

Preparation of hospitals and health systems has been largely applied anticipating a uniform surge of patients requiring either isolated medical ward rooms or intensive care and mechanical ventilation. This this form of readiness planning is not responsive to the clustering of cases that has been observed across the globe.

The COVID-19 outbreaks have occurred in hotspots signaling an opportunity to move or shift resources from centers with little or no exposure to those who are at risk for or indeed are becoming overwhelmed with COVID-19 patients.

To help countries increase their preparedness, this paper paper focuses on two scalable and readily available methods of mass reporting of COVID-19 cases in real time:

Proposal #1: A mobile phone application that is freely downloadable and operationalized for one user and allowing for geographic tracking and self reporting of an illness consistent with COVID-19, disclosure of positive/negative testing if performed, and actions taken including self-quarantine, emergency department or clinic visit, or hospitalization. Additionally, such an app will allow reporting of recovery in nonfatal cases.

Proposal #2: Effective immediately and under government order if necessary, each and every hospital in the world should have a protocol to report each and every case of confirmed COVID-19 to a reporting agency that services that part of the world in which the hospital is situated.

The paper also calls for immediate and mandatory daily hospital census reporting of hospitalized and critical ill COVID-19 patients.

Published on :  | By Erika Cheng

Review: Denominator matters in estimating COVID-19 mortality rates

This article explains why the current mortality rates of COVID-19 should not be compared between countries.

The novel coronavirus disease 2019 (COVID-19) continues to spread internationally. Worldwide, almost 700,000 cases and 33,000 deaths have been reported. The WHO estimates the global mortality rate to be 3.4% but this varies between countries and across ages.

However the current mortality rate of COVID-19 might be skewed which doesn’t allow for a direct comparison between countries. County-level COVID-19 mortality rates rely on the number of deaths scaled to the number of confirmed COVID-19 cases. The denominator should be the total number of patients diagnosed with the virus in a country, but this is hard to estimate. The WHO, the National Data, and other sources have provided data on the cumulative number of cases being placed as the denominator while estimating mortality rates, which may not be appropriate since testing strategies across countries vary. Some countries used the strategy of testing symptomatic individuals with probably a high viral shedding, while other countries also tested many asymptomatic people, leading to an increase in the number of cases.

Other estimates use the number of COVID-19 patients who require admission to hospitals as the denominator while estimating the current mortality rates of COVID-19. However, here again, caution is needed as the differences in rates may reflect the heterogeneity in: (i) the clinical management and care of COVID-19 patients which may vary across countries or (ii) the guideline of admission to hospital for patients with confirmed COVID-19.

The author of this piece suggests that the final denominator to calculate the COVID-19 mortality rate may not be available or may be unknown for now. Therefore, comparison between countries should require other metrics such as: (i) the comparability between healthcare systems; (ii) the population size; (iii) the number of days since the date of the first diagnosed COVID-19 case; (iv) the heterogeneity in testing strategies across countries, for example testing symptomatic individuals in France with mostly a high viral shedding vs. testing asymptomatic individuals in South Korea or Germany; (v) the guidelines of admission to hospital for patients with confirmed COVID-19; and (vi) the variability in assessing the number of deaths per day, for example the number of deaths mentioned in France corresponds to the number of deaths in hospital.

This panel report contains five main and three additional recommendations intended to help medical practitioners use CXR and CT in the management of COVID-19.

While mild cases of COVID-19 appear like other common upper respiratory viral infections, more severe cases involve respiratory dysfunction as the principal source of morbidity and mortality. Chest X-rays and computed tomography (CT) are useful tools for pulmonary disease diagnosis and management, but their role in the management of COVID-19 is not well understood. We do not have solid data on pre-test probability, risk factors for disease progression, and critical resource constraints.

This multidisciplinary panel of radiologists and pulmonologists from 10 countries with experience managing COVID-19 patients evaluated the utility of imaging in 3 scenarios over a variety of risk factors, community conditions, and resource constraints. They answered 14 key questions, corresponding to 11 decision points within the 3 scenarios and 3 additional clinical situations.

This modeling study describes a publicly available system designed for hospital operations leaders that can inform preparations for capacity strain under the COVID-19 pandemic.

This study used a Monte Carlo simulation to estimate the timing of surges for clinical resources, as well as the best- and worst-case scenarios of local COVID-19–induced strain on hospital capacity. It was based on three hospitals in an academic health system in the greater Philadelphia region.

The COVID-19 Hospital Impact Model (CHIME) model, using patients with COVID-19 alone, estimated that it would be 31 to 53 days before demand exceeds existing hospital capacity. In best- and worst-case scenarios, the total needed hospital beds would reach 3131 to 12 650 across the 3 hospitals, including 338 to 1608 ICU beds and 118 to 599 ventilators.

This cohort study suggests that laboratory levels of LDH, CRP, ALT and NEU can be useful in predicting the results of COVID-19 test.

This diagnostic accuracy study sought to determine the accuracy of laboratory parameters in predicting cases with positive RT-PCR for COVID-19. Researchers evaluated 200 cases of potential COVID-19. RT-PCR was positive in 35% cases. Patients with positive RT-PCR had significantly higher neutrophil counts, C-reactive protein, lactate dehydrogenase , aspartate aminotransferase, alanine aminotransferase, and Urea levels in serum.

Patients with positive RT-PCR also had lower white blood cell count and serum albumin levels.

They determined that ALT, CRP, NEU, LDH, and Urea had very good accuracy in predicting cases with positive RT-PCR for COVID-19.

This case series showed convalescent plasma was well tolerated and has potential to improve the clinical outcomes of severe COVID-19 cases. The optimal dose and timing, as well as the true clinical benefit, needs further study in larger well-controlled trials.

Researchers enrolled 10 severely infected patients with COVID-19. Each was given one dose of 200 mL of convalescent plasma derived from recently recovered donors with neutralizing antibody titers above 1:640. They were also given supportive care and antiviral agents.

The median time from illness onset to convalescent plasma transfusion was 16-17 days. After convalescent plasma transfusion, the level of neutralizing antibody increased rapidly up to 1:640 in five cases, and four others maintained a high level (1:640). The clinical symptoms were significantly improved, as was oxyhemoglobin saturation in 3 days. Other parameters that improved included lymphocyte counts and C-reactive protein.

Radiological examinations showed varying levels of improvement. The viral load was undetectable after transfusion in seven patients who detectable levels beforehand. No severe adverse effects were observed.

This review discussed how clinical decision scores can be used to make decisions about ICU care in the COVID-19 pandemic and tests three scores in the current environment.

It’s very possible that the COVID-19 pandemic may overwhelm healthcare resources in particular areas. This includes personnel. In such cases, decisions will have to be made as to who should be admitted and cared for in ICUs.

Clinical decision scores can support such decision-making, but they will require adaptation to the pandemic and the patient being treated. The authors of this article discuss using clinical prediction scores for pneumonia severity at 3 main decision points to discuss how they might help decision makings in this domain. They compared data from a cohort of over 44,000 infected patients in China, including risk factors for mortality, to data from cohorts used to study the clinical scores. By doing so they were able to estimate the potential appropriateness of each score and how it might be used in the current environment.

Published on :  | By Maria Brann

Review: Communication skills in the age of COVID-19

This article offers health care providers evidence-based principles for communicating with sick patients during a community health crisis.

Communication challenges with sick patients have been exacerbated with the COVID-19 pandemic. Health care providers are facing patients with extreme levels of apprehension, uncertainty, and fear as they deliver serious diagnoses and prognoses and attempt to discuss goals of care. Evidence-based communication methods exist to train clinicians in how to communicate with patients with serious illness. Specifically, health care providers are reminded of three core principles:

  • Dealing with emotion is more important than providing a lot of information
  • Information is best delivered in small doses with the most important information first
  • Patient values should be at the heart of medical treatment plans

These principles are important for patients to feel valued and heard, and they provide patients with the information needed in ways that they can process and manage. However, health care providers must manage the third principle with the realization that under crisis standards, individual values must shift to population-based resource allocation. Therefore, providers need to explain what specific care is possible for each specific patient. High-quality communication is an essential part for patients and clinicians to survive well.

Published on :  | By Erika Cheng

Review: Cryptic transmission of SARS-CoV-2 in Washington State

This paper outlines that COVID-19 circulated cryptically and was undetected 4-6 weeks before the first community transmission case was detected at Seattle. Mass testing will enable public health officials to detect and track these under-detected community cases.

Following its emergence in Wuhan, China, in late November or early December 2019, the SARS-CoV-2 virus has rapidly spread throughout the world. On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) a pandemic.

Genome sequencing of SARS-CoV-2 strains allows for the reconstruction of transmission history connecting these infections. This study presents an analysis of 346 SARS-CoV-2 genomes from samples collected between 20 February and 15 March 2020 from infected patients in Washington State, USA.

The authors found that the large majority of SARS-CoV-2 infections sampled during this time frame appeared to have derived from a single introduction event into the state in late January or early February 2020 and subsequent local spread. This strongly suggests cryptic spread of COVID-19 during the months of January and February 2020, before active community surveillance was implemented.

We estimate a common ancestor of this outbreak as occurring between 18 January and 9 February 2020.

From genomic data, we estimate an exponential doubling between 2.4 and 5.1 days.

These results highlight the need for large-scale community surveillance for SARS-CoV-2 introductions and spread and the power of pathogen genomics to inform epidemiological understanding.

This study describes the use of pooled screening strategies to detect early community transmission of COVID-19.

COVID-19 has shown us the importance of robust diagnostic testing. Given the limited testing capacity available in the US, people symptoms, but without travel or exposure history, were not tested. We do not have an accurate picture of the community circulation of the virus prior to the identification of individuals with positive results.

Sample pooling, a strategy used for community monitoring of other infectious diseases such as trachoma, might be deployed. Researches gathered all nasopharyngeal and bronchoalveolar lavage samples collected from Jan 1- Feb26, from inpatients and outpatients who had negative results by routine respiratory virus testing. Nine or 10 individual samples were pooled, and screening was performed using RT-PCR. Positive pools were deconvoluted and individual samples tested for confirmation.

A total of 292 pools were screened, consisting of  2740 nasopharyngeal samples and 148 bronchoalveolar lavage samples. The positivity rate for COVID was 0.07%. They found that the positive results were from nasopharyngeal samples collected from Feb 21-23.

This review article details important considerations in providing critical care to patients with COVID-19.

Initial reports gave us reason to believe that about 5% of proven infections required critical care. Given how infectious the virus is, critical care will be needed in great amounts. Hospitals and health care systems will be challenged. In areas of China without enough capacity, case-fatality rates were seven times higher (2.9% versus 0.4%).

This article reviews critical care for patients with COVID-19, including:

  • Factors Associated With Requiring Intensive Care
  • Differentiating From Other Diseases
  • Clinical Management and Outcomes
  • Protecting Patients and Health Care Workers
  • Surge Preparation
  • Major Knowledge Gaps


This Health Affairs post urges that state Departments of Health to provide “consistent standardized public reporting on cumulative COVID-19 hospitalizations, cumulative COVID-19 patients admitted to the ICU, current COVID-19 patients hospitalized, and current COVID-19 patients in the ICU.”

The authors urge states to be more consistent with data reporting so that COVID-19 data can be shared and more useful “in quantifying the real-time impact on hospital systems, modeling and forecasting upcoming utilization needs, identifying opportunities for sharing medical resources across states, and tracking the rate of change of disease severity.” States are reporting various types of data, and the number of deaths is the only consistent and reliable daily data from all 50 states. COVID-19 hospitalizations (current and cumulative) are not consistently reported. Currently, Indiana is among 14 states not regularly reporting hospitalization data.

In this Australian news article, health care providers demand government officials to provide consistent information related to COVID-19.

Other countries can learn from the ineffectiveness of the inconsistent messages Australian government leaders and public health officials have been disseminating. General practitioners expressed frustration over the lack of consistent advice being given to health professionals and the public. Without consistent messages, health care providers are unsure of how best to protect themselves and their patients during the spread of COVID-19. Up-to-date, unified information must be communicated clearly by both the government and public health organizations.

COVID-19 Digest Links
Creative Commons License The literature reviews on this blog were created under a Creative Commons Attribution-NonCommercial 4.0 International License , which allows the reuse and adaptation of the work by noncommercial entities. These rights do not extend to the articles that the authors are reviewing.
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