#YearofCOVID: The Evolution of Care
First in a Series About Cedars-Sinai's Challenges, Breakthroughs and Heroes During the COVID-19 Pandemic
One year has passed since stay-at-home orders went into effect across the U.S. and the COVID-19 pandemic changed our lives in profound ways. The novel coronavirus has infected more than 100 million worldwide and killed more than 2.5 million, including more than 500,000 in the U.S alone. It has separated many from their loved ones and cost others their jobs, their homes and their life savings.
But in a dark year, we’ve also witnessed courageous patients and heroic healthcare workers battling the disease, as swift scientific breakthroughs have brought us vaccines and hope.
During March, the Cedars-Sinai Newsroom team is marking this one-year pandemic milestone with a series reflecting on the past 12 months as experienced by our patients, healthcare workers, researchers and community. Follow and join the conversation on social media @CedarsSinai
In the Beginning
Peter Chen, MD, remembers those early days of March 2020 as one of swirling hyperactivity in the intensive care unit he leads at Cedars-Sinai. Chen and his team were struggling to respond to an emerging health crisis that was quickly growing into a global pandemic.
In California, the rapidly spreading novel coronavirus prompted state officials to shutter all but essential businesses and services, close schools and order everyone to shelter in place. People fashioned bandanas into face masks to protect themselves. As the weeks went by, frightened patients streamed into hospital emergency rooms, and deaths began mounting in intensive care units and nursing homes.
“We started to see more and more patients in the ICU who were in respiratory distress, some so ill they needed to be intubated," recalls Chen, director of Pulmonary and Critical Care Medicine at Cedars-Sinai. "We knew these were cases of COVID-19 caused by the SARS-CoV-2 virus, a respiratory virus, but there were not many good antiviral medications available. We needed to effectively treat their symptoms while we gained more knowledge, fast.”
The fog of those early months would slowly lift, revealing new paths to the effective treatment of patients infected with the novel coronavirus. Gradually, despite repeated surges in hospitalizations, the mortality rate across the U.S. would decline. The evolution of patient care and the development of effective drug therapies would play critical roles in reducing deaths and hospitalizations and improving patient outcomes. But in the early days of the pandemic, doctors, nurses, respiratory therapists and others on the front lines faced the challenging task of blunting a virus few fully understood.
“New battle fronts in a war often need new weapons," Chen said. "And we were in a war."
A Lifeline in the Trenches
Providing lifesaving care is often time-consuming. Inserting a central venous catheter in the sickest COVID-19 patients to monitor body functions, sample blood and deliver medicines is imperative. However, inserting these central lines can sometimes take more than an hour with the donning and doffing of personal protective equipment (PPE).
Eduardo Marbán, MD, PhD, executive director of the Smidt Heart Institute, thought heart specialists could provide an innovative solution. Working with cardiologist Evan Zahn, MD, they created a team of vascular specialists who could take over the time-consuming but vital job of inserting these catheters and help free up ICU staff to focus on patient care. Zahn recruited about 20 colleagues who call themselves the COVID Line Team and they continue to play that vital role on the front lines of COVID-19 care. A parallel Airway Team of anesthesiologists intubated patients as needed. The two teams coordinated their efforts, speeding up the delivery of care and making the ICU operation more efficient.
“When the largest healthcare crisis of my entire life is right in front of me, I had to find a way to help," said Zahn, director of the Guerin Family Congenital Heart Program. "I didn’t get into medicine to sit on the sidelines while patients suffer and colleagues are overwhelmed.”
Every Breath They Take
While the disease of COVID-19 can affect a variety of body functions, it is most often a respiratory infection. In critically ill patients, every breath can be a struggle. Respiratory therapists are key players in patient care, spending much of their time near a patient’s head and close to their airways.
“Some COVID patients need medication through a nebulizer to open their lungs," said Lashone Mays, the interim associate director for Respiratory Therapy at Cedars-Sinai. "There may be problems with the ventilator, or patients go into respiratory distress. In all those situations, there is a risk of our respiratory therapists being exposed to virus shed in a cough or in aerosolized droplets exhaled after a nebulizer treatment.”
While respiratory therapists are clothed in protective gear, an added layer of safety was introduced. Instead of receiving medications by nebulizers, which can produce microscopic spray, patients received their medications via special inhalers that minimized the risk of spreading the virus.
To keep Cedars-Sinai frontline healthcare workers safe, changes also were made to the workflow of respiratory therapists to limit how much time they would spend in a patient’s room and how they would operate ventilators or administer other treatment, says Mays.
As the pandemic progressed, Cedars-Sinai medical staff worked around the clock, across time zones and oceans, to learn more about COVID-19 and identify effective treatments. They swapped critical information with colleagues in Washington state, New York, Italy, and China─early hot spots for the coronavirus.
One simple tool helping those hospitalized with COVID-19 was something pulmonologists had used for years when caring for patients with acute respiratory distress syndrome (ARDS)–flipping them onto their stomachs for long periods of the day.
“Very early on we did a lot of proning of the COVID patients in the ICU, and it helped," Chen said. "Studies prior to COVID had shown that turning patients over improved the outcomes of ARDS patients—there is better expansion of the lungs and better blood flow to the healthier part of the organ. Proning helped with oxygenation and breathing, and we’re still doing that."
A Pandemic with a Panoply of Symptoms and Conditions
During the initial COVID-19 surge in the U.S., deaths averaged more than 2,100 during one distressing week in April 2020. At the same time, the understanding of the disease as a viral attack on the lungs was evolving. Other organ systems were also being affected by the virus.
Even as ICU teams sought to get a handle on respiratory failure, they began seeing more virus-positive patients in the ICU who had blood-clotting problems, heart damage, kidney failure, and extreme diarrhea that caused dangerous dehydration. The teams also observed the development of what would come to be known as “COVID brain” in some patients, a kind of agitation and delirium.
As the pandemic wore on, it also became clear that some racial groups were more vulnerable than others. Black, Latinx, Native American and Alaska Native people were three times more likely to be hospitalized than white people and twice as likely to die from COVID-19, according to the Centers for Disease Control and Prevention (CDC). Having underlying health conditions, such as severe obesity or kidney disease, and being male, also appeared to elevate the risk for severe COVID-19 illness. Still, many in the population—especially the young—developed only mild symptoms or none at all.
“It is a confounding virus," Chen said. "It was clear our best option was the development of new drug therapies to keep an initial viral infection from mounting a fatal attack on patients."
Effective Treatments Emerge in Record Time
An important turning point in the battle against COVID-19 has been the availability of several drugs approved by the Food and Drug Administration (FDA) for emergency use. Chief among these has been the three vaccines that have received FDA approval. But others have played pivotal roles as well.
The antiviral medication remdesivir has proven to be an effective therapy for patients with mild-to-moderate COVID-19. The inexpensive and widely available steroid dexamethasone, a powerful anti-inflammatory medicine, also significantly lowered mortality rates among patients already on ventilators or other oxygen support.
Fast-tracked studies also found that neutralizing monoclonal antibodies could have remarkable success in preventing patients from becoming very sick. The laboratory-produced antibodies prevent the SARS-CoV-2 virus from replicating in the body; the invasion is halted soon after it begins. Chen led research at Cedars-Sinai as part of the multicenter investigation of monoclonal antibody therapy and co-authored a paper published in the New England Journal of Medicine.
"For me, the most significant finding was the potential to reduce hospitalizations," he said. "Monoclonal antibodies like this have the potential to reduce the severity of COVID-19 for many patients, allowing more people to recover at home."
Nurses: Critical Utility Players
Nursing care is often described as the foundation on which hospitals are built.
Cross-trained and ready to redeploy–terms usually associated with a military campaign—are good ways to describe the evolution of nurse readiness at Cedars-Sinai during the pandemic. These healthcare specialists were asked continually to pivot quickly to the unique demands of providing high-quality healthcare during a global medical crisis.
“Cross-training nurses has been essential to meeting the staffing demands we’re experiencing during the pandemic. Every surge seems different and requires experienced nurses to pivot and augment their skills or be reassigned to a new area of acute need in our healthcare system,” said Todd Griner, DPN, RN, executive director of Critical Care Services.
"Nurses continue to show their agility in transforming care as needed to respond to the ever-changing needs of our patients and our organization. They do not sit on the sidelines; they want to be part of the solution,” said Margo Minissian, PhD, ACNP, executive director of the
Geri and Richard Brawerman Nursing Institute and the Simms/Mann Family Foundation Chair in Nurse Education, Innovation and Research.
The Future of COVID-19 Care: Recovery Support
When it comes to the next 12 months, Chen is cautiously optimistic.
“We’re getting better," Chen said. "The declining numbers in hospitalized patients, the continued search for new and better therapies and lower rates of transmission are hopeful signs. But this virus has tripped us up many times and I think we always have to be vigilant.”
One emerging frontier of pandemic care is healthcare for patients who are no longer infected or in critical condition but continue to experience medical problems.
Cedars-Sinai has launched the COVID-19 Recovery Program to meet the needs of these growing numbers of patients who face persistent medical challenges weeks and even months after they are virus-free. For patients experiencing heart problems, in particular, there is also a Post COVID-19 Cardiology Program in the Smidt Heart Institute.
“In medicine we always tell patients that recovery is a process," Chen said. "When it comes to our health systems’ recovery from the major impact of the pandemic, that is also true. But we will all get there."
Read More in Discoveries magazine: COVID-19 Vaccine: Questions Answered