September 14, 2020

An article review from the ESICM Journal Review Club

A rational approach of resource utilisation during the COVID-19 pandemic is mandatory. How can we make it feasible?

Since the beginning of the COVID-19 pandemic, the world has been racing to contain the spread of the virus and mitigate its consequences. This has not been an easy task. The lack of commonly available, targeted medications and vaccines leads to the realisation that this virus might be with us for some time, inflicting severe consequences upon healthcare systems, even the most advanced ones.

Several of the countries have managed to exit the first stage of the disease, with variations in success and efficiency, but the disease seems to be coming back for a second round.

Because of the rapidly evolving and constantly changing situation, clinicians and policy makers need reviews and summaries of the ever-expanding literature, given the paucity of evidence-based practice to deal with this novel disease. This rapid guideline article aims to provide suggestions on the logistical and resource utilisation strategies, rather than clinical insights of treating COVID-19.

The core team of the committee are all members of the panel and leadership of the Surviving Sepsis Campaign COVID-19 guidelines, which adds validity to the statements. The questions were finalised following discussion and consensus and formatted according to population, intervention, comparator and outcome (PICO) where this was feasible.

This guideline employs the terms “we recommend” for strong recommendations and “we suggest” for weak recommendations. “Strong recommendation” corresponds to Best Practice statements.

The questions are pragmatic and span the whole range of organisational management of ICUs caring for COVID-19 patients. These issues address the burden of COVID-19 on critical care, taking into consideration hardware use, supplies, equipment prediction and patient turnover. Moreover, they describe available strategies to overcome potential shortages in ventilators and beds, intensive care staffing, PPE availability and healthcare exposure to COVID-19.

Other issues addressed include triage procedures, the need for a legal framework during a surge event, and the support of family and staff.

Only three recommendations are “strong”, and two of them are based on low-quality evidence, and one on “moderate”. “Weak” recommendations, based on low-quality evidence, or very low certainty of evidence account for 20 statements, while “best practice” statements account for 22 recommendations.
All of these are presented in a very comprehensive first table.

I especially need to comment on the second table of this article, which presents an estimate of the supplies required to manage an intubated ICU patient during the COVID-19 (or pandemic) surge. It is highly laconic, concise and utilitarian in its presentation. It describes supplies, equipment and medication, including types, quantity and projected requirements. One important caveat of this table though, is a possible underestimation of the actual requirements, which is also acknowledged by the authors. This is concluded because COVID-19 patients appear to have greater Length of Stay and Mechanical Ventilation Days in comparison to non-COVID-19 patients, which may lead to the underestimation of the actual requirements.

 

STUDY STRENGTHS & LIMITATIONS

Strengths

• Unique and very relevant rapid guidelines, addressing several serious questions.
• Simplified and useful charts and figures.
• Panel of experts at the forefront of this epidemic validate the findings.

Limitations

• The gravity of the statements is not very strong since the literature is (at best) still expanding, or (at worst) sometimes controversial or insufficient. There is a lack of strong, evidence-based research, and hence this is overall, an expert-opinion recommendation.
• As the pandemic progresses and we approach the brink of a possible second wave, some of the proposals of this article may need re-evaluation.
• More than 75% of the experts originated from North America and the developed countries in Europe. Asia was represented by only one member from China. One member was included from South America and the Middle East was represented by two. Oceania and Africa were not represented and India (more than three million cases), Russia (almost a million cases), South Africa (fifth globally in total cases), and Spain (most cases in Europe) did not participate. This means that the universal applicability of the statements might be questionable.

 

TAKE HOME MESSAGE

We should try to make up for time and effort and rationalise our resources, because this pandemic is not over yet and evidence-based practice is continuing to evolve.

 

This article review was prepared and submitted by Dr Dimitrios Papadopoulos MD, MSc, PhD, Senior Consultant in Intensive Care Medicine, General Hospital of Larisa, Larisa, Greece, on behalf of the ESICM Journal Review Club.


REFERENCES
  1. Aziz, S., Arabi, Y.M., Alhazzani, W. Et al. Managing ICU surge during the COVID-19 crisis: rapid guidelines. Intensive Care Med 46, 1303–1325 (2020).

Comment on this news