RESUMEN
OBJECTIVES: Nonconventional ventilators (NCVs), defined here as transport ventilators and certain noninvasive positive pressure devices, were used extensively as crisis-time ventilators for intubated patients with COVID-19. We assessed whether there was an association between the use of NCV and higher mortality, independent of other factors. DESIGN: This is a multicenter retrospective observational study. SETTING: The sample was recruited from a single healthcare system in New York. The recruitment period spanned from March 1, 2020, to April 30, 2020. PATIENTS: The sample includes patients who were intubated for COVID-19 acute respiratory distress syndrome (ARDS). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was 28-day in-hospital mortality. Multivariable logistic regression was used to derive the odds of mortality among patients managed exclusively with NCV throughout their ventilation period compared with the remainder of the sample while adjusting for other factors. A secondary analysis was also done, in which the mortality of a subset of the sample exclusively ventilated with NCV was compared with that of a propensity score-matched subset of the control group. Exclusive use of NCV was associated with a higher 28-day in-hospital mortality while adjusting for confounders in the regression analysis (odds ratio, 1.41; 95% CI [1.07-1.86]). In the propensity score matching analysis, the mortality of patients exclusively ventilated with NCV was 68.9%, and that of the control was 60.7% ( p = 0.02). CONCLUSIONS: Use of NCV was associated with increased mortality among patients with COVID-19 ARDS. More lives may be saved during future ventilator shortages if more full-feature ICU ventilators, rather than NCVs, are reserved in national and local stockpiles.
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COVID-19 , Mortalidad Hospitalaria , Síndrome de Dificultad Respiratoria , Ventiladores Mecánicos , Humanos , COVID-19/terapia , COVID-19/mortalidad , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Síndrome de Dificultad Respiratoria/terapia , Síndrome de Dificultad Respiratoria/mortalidad , Ventiladores Mecánicos/provisión & distribución , Ventiladores Mecánicos/estadística & datos numéricos , New York/epidemiología , Respiración Artificial/estadística & datos numéricosAsunto(s)
COVID-19/epidemiología , COVID-19/terapia , Cuidados Críticos/organización & administración , Triaje/organización & administración , Ventiladores Mecánicos/provisión & distribución , Negro o Afroamericano , Anciano , Protocolos Clínicos , Simulación por Computador , Femenino , Hispánicos o Latinos , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Método de Montecarlo , Selección de Paciente , Tasa de Supervivencia , Población BlancaRESUMEN
In the first months of the COVID-19 pandemic in Europe, many patients were treated in hospitals using mechanical ventilation. However, due to a shortage of ICU ventilators, hospitals worldwide needed to deploy anesthesia machines for ICU ventilation (which is off-label use). A joint guidance was written to apply anesthesia machines for long-term ventilation. The goal of this research is to retrospectively evaluate the differences in measurable ventilation parameters between the ICU ventilator and the anesthesia machine as used for COVID-19 patients. In this study, we included 32 patients treated in March and April 2020, who had more than 3 days of mechanical ventilation, either in the regular ICU with ICU ventilators (Hamilton S1), or in the temporary emergency ICU with anesthetic ventilators (Aisys, GE). The data acquired during regular clinical treatment was collected from the Patient Data Management Systems. Available ventilation parameters (pressures and volumes: PEEP, Ppeak, Pinsp, Vtidal), monitored parameters EtCO2, SpO2, derived compliance C, and resistance R were processed and analyzed. A sub-analysis was performed to compare closed-loop ventilation (INTELLiVENT-ASV) to other ventilation modes. The results showed no major differences in the compared parameters, except for Pinsp. PEEP was reduced over time in the with Hamilton treated patients. This is most likely attributed to changing clinical protocol as more clinical experience and literature became available. A comparison of compliance between the 2 ventilators could not be made due to variances in the measurement of compliance. Closed loop ventilation could be used in 79% of the time, resulting in more stable EtCO2. From the analysis it can be concluded that the off-label usage of the anesthetic ventilator in our hospital did not result in differences in ventilation parameters compared to the ICU treatment in the first 4 days of ventilation.
Asunto(s)
Anestesiología/instrumentación , COVID-19 , Respiración Artificial/métodos , Ventiladores Mecánicos , Anciano , COVID-19/terapia , Europa (Continente) , Humanos , Unidades de Cuidados Intensivos , Persona de Mediana Edad , Pandemias , Estudios Retrospectivos , Ventiladores Mecánicos/provisión & distribuciónAsunto(s)
COVID-19/terapia , Enfermedad Crítica/terapia , Respiración Artificial/métodos , Ventiladores Mecánicos/provisión & distribución , Anciano , COVID-19/epidemiología , Estudios de Cohortes , Enfermedad Crítica/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: This focus article is a theoretical reflection on the ethics of allocating respirators to patients in circumstances of shortage, especially during the coronavirus disease-2019 (COVID-19) outbreak in Israel. In this article, respirators are placeholders for similar life-saving modalities in short supply, such as extracorporeal membrane oxygenation machines and intensive care unit beds. In the article, I propose a system of triage for circumstances of scarcity of respirators. The system separates the hopeless from the curable, granting every treatable person a real chance of cure. The scarcity situation eliminates excesses of medicine, and then allocates respirators by a single scale, combining an evidence-based scoring system with risk-proportionate lottery. The triage proposed embodies continuity and consistency with the healthcare practices in ordinary times. Yet, I suggest two regulatory modifications: one in relation to expediting review of novel and makeshift solutions and the second in relation to mandatory retrospective research on all relevant medical data and standard (as opposed to experimental) interventions that are influenced by the triage.
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COVID-19/terapia , Asignación de Recursos/ética , Triaje/métodos , Ventiladores Mecánicos/provisión & distribución , COVID-19/epidemiología , Brotes de Enfermedades , Análisis Ético , Oxigenación por Membrana Extracorpórea/instrumentación , Humanos , Unidades de Cuidados Intensivos/ética , Unidades de Cuidados Intensivos/provisión & distribución , Israel , Triaje/ética , Ventiladores Mecánicos/éticaRESUMEN
Ventilator shortages occurred due to the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This in vitro study evaluated the effectiveness of 3-dimensional (3D)-printed splitters and 3D-printed air flow limiters (AFL) in delivering appropriate tidal volumes (TV) to lungs with different compliances. Groups were divided according to the size of the AFL: AFL-4 was a 4-mm device, AFL-5 a 5-mm device, AFL-6 a 6-mm device, and no limiter (control). A ventilator was split to supply TV to 2 artificial lungs with different compliances. The AFL improved TV distribution.
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COVID-19/epidemiología , COVID-19/terapia , Servicios Médicos de Urgencia/métodos , Rendimiento Pulmonar/fisiología , Impresión Tridimensional , Ventiladores Mecánicos/provisión & distribución , Humanos , Pulmón/fisiología , Masculino , Volumen de Ventilación Pulmonar/fisiologíaAsunto(s)
Infecciones por Coronavirus/terapia , Sistemas de Información en Hospital/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Capacidad de Reacción , Australia , Infecciones por Coronavirus/epidemiología , Recolección de Datos , Humanos , Pandemias , SARS-CoV-2 , Ventiladores Mecánicos/provisión & distribución , Recursos HumanosRESUMEN
Saiba mais em www.saopaulo.sp.gov.br/coronavirus
Asunto(s)
Infecciones por Coronavirus/prevención & control , Neumonía Viral/prevención & control , Pandemias/prevención & control , Capacidad de Camas en Hospitales/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Sistemas Locales de Salud/organización & administración , Ventiladores Mecánicos/provisión & distribuciónRESUMEN
The COVID-19 pandemic has created unprecedented challenges worldwide. Strained healthcare providers make difficult decisions on patient triage, treatment and care management on a daily basis. Policy makers have imposed social distancing measures to slow the disease, at a steep economic price. We design analytical tools to support these decisions and combat the pandemic. Specifically, we propose a comprehensive data-driven approach to understand the clinical characteristics of COVID-19, predict its mortality, forecast its evolution, and ultimately alleviate its impact. By leveraging cohort-level clinical data, patient-level hospital data, and census-level epidemiological data, we develop an integrated four-step approach, combining descriptive, predictive and prescriptive analytics. First, we aggregate hundreds of clinical studies into the most comprehensive database on COVID-19 to paint a new macroscopic picture of the disease. Second, we build personalized calculators to predict the risk of infection and mortality as a function of demographics, symptoms, comorbidities, and lab values. Third, we develop a novel epidemiological model to project the pandemic's spread and inform social distancing policies. Fourth, we propose an optimization model to re-allocate ventilators and alleviate shortages. Our results have been used at the clinical level by several hospitals to triage patients, guide care management, plan ICU capacity, and re-distribute ventilators. At the policy level, they are currently supporting safe back-to-work policies at a major institution and vaccine trial location planning at Janssen Pharmaceuticals, and have been integrated into the US Center for Disease Control's pandemic forecast.
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Tratamiento Farmacológico de COVID-19 , COVID-19 , Aprendizaje Automático , Anciano , COVID-19/mortalidad , COVID-19/fisiopatología , Bases de Datos Factuales , Femenino , Predicción , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Pandemias , Formulación de Políticas , Pronóstico , Medición de Riesgo/estadística & datos numéricos , SARS-CoV-2 , Ventiladores Mecánicos/provisión & distribuciónRESUMEN
The COVID-19 pandemic raised distinct challenges in the field of scarce resource allocation, a long-standing area of inquiry in the field of bioethics. Policymakers and states developed crisis guidelines for ventilator triage that incorporated such factors as immediate prognosis, long-term life expectancy, and current stage of life. Often these depend upon existing risk factors for severe illness, including diabetes. However, these algorithms generally failed to account for the underlying structural biases, including systematic racism and economic disparity, that rendered some patients more vulnerable to these conditions. This paper discusses this unique ethical challenge in resource allocation through the lens of care for patients with severe COVID-19 and diabetes.
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COVID-19/terapia , Complicaciones de la Diabetes/terapia , Diabetes Mellitus/terapia , Asignación de Recursos , COVID-19/complicaciones , COVID-19/epidemiología , Complicaciones de la Diabetes/economía , Complicaciones de la Diabetes/epidemiología , Diabetes Mellitus/economía , Diabetes Mellitus/epidemiología , Accesibilidad a los Servicios de Salud/economía , Accesibilidad a los Servicios de Salud/ética , Accesibilidad a los Servicios de Salud/normas , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en el Estado de Salud , Disparidades en Atención de Salud/economía , Disparidades en Atención de Salud/ética , Disparidades en Atención de Salud/organización & administración , Disparidades en Atención de Salud/estadística & datos numéricos , Humanos , Pandemias , Racismo/ética , Racismo/estadística & datos numéricos , Asignación de Recursos/economía , Asignación de Recursos/ética , Asignación de Recursos/organización & administración , Asignación de Recursos/estadística & datos numéricos , Triaje/economía , Triaje/ética , Estados Unidos/epidemiología , Ventiladores Mecánicos/economía , Ventiladores Mecánicos/estadística & datos numéricos , Ventiladores Mecánicos/provisión & distribuciónAsunto(s)
COVID-19/terapia , Sedación Profunda/métodos , Hipnóticos y Sedantes/administración & dosificación , Respiración Artificial , Atracurio/administración & dosificación , Atracurio/análogos & derivados , Reconversión de Camas/estadística & datos numéricos , Capacidad de Camas en Hospitales/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Rendimiento Pulmonar , Bloqueantes Neuromusculares/administración & dosificación , Quirófanos/estadística & datos numéricos , Estupor/prevención & control , Ventiladores Mecánicos/provisión & distribuciónRESUMEN
OBJECTIVE: In this study, we describe the pattern of bed occupancy across England during the peak of the first wave of the COVID-19 pandemic. DESIGN: Descriptive survey. SETTING: All non-specialist secondary care providers in England from 27 March27to 5 June 2020. PARTICIPANTS: Acute (non-specialist) trusts with a type 1 (ie, 24 hours/day, consultant-led) accident and emergency department (n=125), Nightingale (field) hospitals (n=7) and independent sector secondary care providers (n=195). MAIN OUTCOME MEASURES: Two thresholds for 'safe occupancy' were used: 85% as per the Royal College of Emergency Medicine and 92% as per NHS Improvement. RESULTS: At peak availability, there were 2711 additional beds compatible with mechanical ventilation across England, reflecting a 53% increase in capacity, and occupancy never exceeded 62%. A consequence of the repurposing of beds meant that at the trough there were 8.7% (8508) fewer general and acute beds across England, but occupancy never exceeded 72%. The closest to full occupancy of general and acute bed (surge) capacity that any trust in England reached was 99.8% . For beds compatible with mechanical ventilation there were 326 trust-days (3.7%) spent above 85% of surge capacity and 154 trust-days (1.8%) spent above 92%. 23 trusts spent a cumulative 81 days at 100% saturation of their surge ventilator bed capacity (median number of days per trust=1, range: 1-17). However, only three sustainability and transformation partnerships (aggregates of geographically co-located trusts) reached 100% saturation of their mechanical ventilation beds. CONCLUSIONS: Throughout the first wave of the pandemic, an adequate supply of all bed types existed at a national level. However, due to an unequal distribution of bed utilisation, many trusts spent a significant period operating above 'safe-occupancy' thresholds despite substantial capacity in geographically co-located trusts, a key operational issue to address in preparing for future waves.
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COVID-19/epidemiología , Capacidad de Camas en Hospitales , Hospitales/provisión & distribución , Capacidad de Reacción , Ventiladores Mecánicos/provisión & distribución , Ocupación de Camas/estadística & datos numéricos , Inglaterra/epidemiología , Personal de Salud , Humanos , Unidades de Cuidados Intensivos/provisión & distribución , SARS-CoV-2 , Medicina EstatalRESUMEN
BACKGROUND: The institution-wide response of the University of California San Diego Health system to the 2019 novel coronavirus disease (COVID-19) pandemic was founded on rapid development of in-house testing capacity, optimization of personal protective equipment usage, expansion of intensive care unit capacity, development of analytic dashboards for monitoring of institutional status, and implementation of an operating room (OR) triage plan that postponed nonessential/elective procedures. We analyzed the impact of this triage plan on the only academic neurosurgery center in San Diego County, California, USA. METHODS: We conducted a de-identified retrospective review of all operative cases and procedures performed by the Department of Neurosurgery from November 24, 2019, through July 6, 2020, a 226-day period. Statistical analysis involved 2-sample z tests assessing daily case totals over the 113-day periods before and after implementation of the OR triage plan on March 16, 2020. RESULTS: The neurosurgical service performed 1429 surgical and interventional radiologic procedures over the study period. There was no statistically significant difference in mean number of daily total cases in the pre-versus post-OR triage plan periods (6.9 vs. 5.8 mean daily cases; 1-tail P = 0.050, 2-tail P = 0.101), a trend reflected by nearly every category of neurosurgical cases. CONCLUSIONS: During the COVID-19 pandemic, the University of California San Diego Department of Neurosurgery maintained an operative volume that was only modestly diminished and continued to meet the essential neurosurgical needs of a large population. Lessons from our experience can guide other departments as they triage neurosurgical cases to meet community needs.
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COVID-19/epidemiología , Hospitales Universitarios/organización & administración , Neurocirugia/organización & administración , Procedimientos Neuroquirúrgicos/estadística & datos numéricos , Centros Médicos Académicos/organización & administración , Neoplasias Encefálicas/cirugía , COVID-19/diagnóstico , Prueba de Ácido Nucleico para COVID-19 , Prueba Serológica para COVID-19 , California/epidemiología , Derivaciones del Líquido Cefalorraquídeo/estadística & datos numéricos , Procedimientos Quirúrgicos Electivos , Procedimientos Endovasculares/estadística & datos numéricos , Capacidad de Camas en Hospitales , Departamentos de Hospitales/organización & administración , Humanos , Control de Infecciones , Difusión de la Información/métodos , Unidades de Cuidados Intensivos , Laboratorios de Hospital , Sistemas Multiinstitucionales , Quirófanos , Política Organizacional , Equipo de Protección Personal/provisión & distribución , Estudios Retrospectivos , Medición de Riesgo , SARS-CoV-2 , Capacidad de Reacción , Triaje , Procedimientos Quirúrgicos Vasculares/estadística & datos numéricos , Ventiladores Mecánicos/provisión & distribución , Heridas y Lesiones/cirugíaRESUMEN
BACKGROUND: In Japan, public dialogue on allocation of life-saving medical resources remains taboo, and discussion largely has been avoided. RESEARCH QUESTION: Do Japanese health care workers and the general public agree with principles of ventilator allocation developed internationally? STUDY DESIGN AND METHODS: A four-point Likert scale questionnaire was used to assess the extent of agreement or disagreement with internationally developed triage principles for rationing mechanical ventilators during pandemics. Questionnaires were distributed in person or online, and generalized linear models were used to analyze quantitative data. Free-text descriptions were analyzed qualitatively, both deductively and inductively, to compare respondent opinions with those described in previous US studies. RESULTS: Of 3,191 surveys distributed, 1,520 were returned. Allocation of resources to maximize survival from current illness ("save the most lives") was the most popular triage principle, with 95.8% of respondents in agreement. Allocation to ensure a minimum duration of benefit, as determined by predicted prognosis after illness ("ensure minimum duration of benefit"), and allocation to persons who have experienced fewer life stages ("life cycle") obtained agreement of 82.2% and 80.1%, respectively. Withdrawal and reallocation of mechanical ventilators to more appropriate patients was supported by 64.4% of respondents. Only 28.4% of respondents supported the principle of first-come, first-served access to ventilators. INTERPRETATION: Most respondents supported allocation principles developed internationally and disagreed with the idea of first-come, first-served allocation during resource shortages. The Japanese public seems largely to be prepared to discuss the ethical dilemmas and possible solutions regarding fair and transparent allocation of critical care resources as a necessary step in confronting present and future pandemics and disasters.
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Actitud del Personal de Salud , COVID-19/terapia , Asignación de Recursos para la Atención de Salud/organización & administración , Opinión Pública , Ventiladores Mecánicos/provisión & distribución , Adulto , Estudios Transversales , Femenino , Humanos , Japón , Masculino , Persona de Mediana Edad , Selección de Paciente , Percepción , Encuestas y Cuestionarios , TriajeRESUMEN
SUMMARY STATEMENT: The COVID-19 pandemic threatened to overwhelm the medical system of New York City, and the threat of ventilator shortages was real. Using high-fidelity simulation, a variety of solutions were tested to solve the problem of ventilator shortages including innovative designs for safely splitting ventilators, converting noninvasive ventilators to invasive ventilators, and testing and improving of ventilators created by outside companies. Simulation provides a safe environment for testing of devices and protocols before use on patients and should be vital in the preparation for emergencies such as the COVID-19 pandemic.
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COVID-19/epidemiología , Respiración Artificial/métodos , Entrenamiento Simulado/organización & administración , Ventiladores Mecánicos/provisión & distribución , Humanos , Pandemias , SARS-CoV-2RESUMEN
BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has severely affected ICUs and critical care health-care providers (HCPs) worldwide. RESEARCH QUESTION: How do regional differences and perceived lack of ICU resources affect critical care resource use and the well-being of HCPs? STUDY DESIGN AND METHODS: Between April 23 and May 7, 2020, we electronically administered a 41-question survey to interdisciplinary HCPs caring for patients critically ill with COVID-19. The survey was distributed via critical care societies, research networks, personal contacts, and social media portals. Responses were tabulated according to World Bank region. We performed multivariate log-binomial regression to assess factors associated with three main outcomes: limiting mechanical ventilation (MV), changes in CPR practices, and emotional distress and burnout. RESULTS: We included 2,700 respondents from 77 countries, including physicians (41%), nurses (40%), respiratory therapists (11%), and advanced practice providers (8%). The reported lack of ICU nurses was higher than that of intensivists (32% vs 15%). Limiting MV for patients with COVID-19 was reported by 16% of respondents, was lowest in North America (10%), and was associated with reduced ventilator availability (absolute risk reduction [ARR], 2.10; 95% CI, 1.61-2.74). Overall, 66% of respondents reported changes in CPR practices. Emotional distress or burnout was high across regions (52%, highest in North America) and associated with being female (mechanical ventilation, 1.16; 95% CI, 1.01-1.33), being a nurse (ARR, 1.31; 95% CI, 1.13-1.53), reporting a shortage of ICU nurses (ARR, 1.18; 95% CI, 1.05-1.33), reporting a shortage of powered air-purifying respirators (ARR, 1.30; 95% CI, 1.09-1.55), and experiencing poor communication from supervisors (ARR, 1.30; 95% CI, 1.16-1.46). INTERPRETATION: Our findings demonstrate variability in ICU resource availability and use worldwide. The high prevalence of provider burnout and its association with reported insufficient resources and poor communication from supervisors suggest a need for targeted interventions to support HCPs on the front lines.
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COVID-19/terapia , Cuidados Críticos , Personal de Salud/psicología , Recursos en Salud , Fuerza Laboral en Salud , Equipo de Protección Personal/provisión & distribución , Agotamiento Profesional/psicología , Enfermería de Cuidados Críticos , Femenino , Estrés Financiero/psicología , Asignación de Recursos para la Atención de Salud , Capacidad de Camas en Hospitales , Humanos , Masculino , Respiradores N95/provisión & distribución , Enfermeras y Enfermeros/psicología , Enfermeras y Enfermeros/provisión & distribución , Médicos/psicología , Médicos/provisión & distribución , Distrés Psicológico , Dispositivos de Protección Respiratoria/provisión & distribución , Órdenes de Resucitación , SARS-CoV-2 , Encuestas y Cuestionarios , Ventiladores Mecánicos/provisión & distribuciónRESUMEN
The COVID-19 (Coronavirus disease of 2019) pandemic has led to intense conversations about ventilator allocation and reallocation during a crisis standard of care. Multiple voices in the media and multiple state guidelines mention reallocation as a possibility. Drawing upon a range of neuroscientific, phenomenological, ethical, and sociopolitical considerations, the authors argue that taking away someone's personal ventilator is a direct assault on their bodily and social integrity. They conclude that personal ventilators should not be part of reallocation pools and that triage protocols should be immediately clarified to explicitly state that personal ventilators will be protected in all cases.