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Sepsis and COVID-19: Perspectives From a Sepsis Coordinator

Coronavirus disease 2019 (COVID-19) has brought difficulties and disruptions to all corners of the world. As a sepsis coordinator, I can attest that the scientific and healthcare community in the United States has been particularly turned upside down by the novel virus, as our daily tasks and responsibilities have been shifted to respond to the threats accompanied by this virus. 

Over the past few months, healthcare workers have been challenged to quickly make assessments and adjust best practices as a result of the COVID-19 pandemic. Early on in the pandemic, many people believed that this novel virus led to a “flu-like” illness. However, we quickly learned from colleagues in Washington and California that this was definitely not like the flu.

COVID-19 not “just like the flu…”

During the 2018-2019 influenza season there were approximately 34,000 flu-related deaths recorded in the United States.1 It is not uncommon for patients to develop pneumonia and subsequent sepsis, during flu season. However, unlike COVID-19, most healthcare workers are familiar with recognizing and treating influenza.There are fairly accurate tests, vaccines and antivirals, and we have established supportive care such as antipyretics and intravenous fluid. Additionally, we have a good idea of which individuals could be affected adversely by the flu and can be on the guard to quickly identify flu and sepsis. Although nothing is 100%, we have tools in our arsenal to treat and identify flu quickly and save a large number of people from developing the sequelae of pneumonia and sepsis. We are ready when the largest wave of flu begins in mid fall and are always anticipating the end of the season in spring.

COVID-19 has completely disrupted what we have come to expect from flu season and what we plan for each year. COVID-19 went from being thought of as a “flu-like illness” to overwhelming hospital systems, seemingly overnight. While experts had warned that a pandemic was imminent, the United States and the rest of the world were caught flat footed by the virus. Some intensive care units were overwhelmed by patients who quickly went from being moderately ill to critically ill and requiring ventilator support for long periods of time. As a result, patients overflowed into other areas of the hospital, such as post-anesthesia care units and operating rooms, which were turned into makeshift into COVID wards. Nursing staff were redeployed to other areas where nursing care was needed. Clinicians across the United States became very concerned with having enough medications to manage sedation for patients requiring prolonged intubations. “Burn rate” became a buzz word in trying to anticipate how to manage an existing personal protective equipment (PPE) supply and make it last. We were also challenged to evaluate how we used and could reuse PPE to keep healthcare workers safe during challenging times.

Unexpected challenges of COVID-19

It has been hard to predict who will be impacted by COVID-19 and how severely they could be affected. At times, COVID 19 respiratory presentation did not respond using conventional treatments typically used with COPD exacerbations or pneumonia such as steroids or nebulizer treatments.

From a sepsis coordinator’s perspective, the golden hour for rapid antibiotic administration ticked by as we waited for CT scan results which might then reveal multifocal pneumonias and ground glass opacities. We needed to have a high index of suspicion looking for patients we knew could be at risk for COVID-19. Our patients with poorly managed diabetes also became quickly overwhelmed and in need of lifesaving care. Were fluids for patients with suspected COVID-19 infection the best thing to use for septic shock? We needed to carefully consider fluids and document good medical decision making.

Testing for COVID-19 has been problematic. In the first weeks of the pandemic, testing in the United States was not readily available nor was it quick. As a result, we had to treat presumptive COVID-19 cases. As the weeks have passed, testing is now more widely available and results have been returned faster. There is still concern in the validity of the testing. These concerns include what type of sample is collected and by whom, how it is transported, and how it may be affected by things like chlorhexidine gluconate (CHG) baths. Many patients that have had negative test results have later turned up as positive. It has been virtually impossible to predict who will develop symptoms and how severely. 

Deploying best practices in real time

So what have we in healthcare done? We have undertaken what healthcare professionals have set out to do from the beginning. We collaborated and we shared best practices as we learned them. Social media and networking helped clinicians share information from around the globe in real time. Organizations such as the Sepsis Alliance quickly distributed widespread education to sepsis coordinators around the country. 

Was proning more effective than intubation? Were ferritin levels a better prognosis of outcome? New information and manifestations of COVID-19 have been rapidly shared. I saw “COVID toes” in a child before anyone was talking about them because a colleague had shared skin manifestation photos with me. His parent had a difficult time finding someone who was familiar with this and able to diagnose him. He was not sick, and a telehealth visit aided in his diagnosis. No one else in this family was ever ill.  

Expanding and adapting sepsis surveillance

Sepsis accounts for a large number of hospitalizations and readmissions. However, COVID-19 has in fact added to the volume of patients we track for sepsis. An unmeasured, though unintended consequence of the pandemic is the number of individuals who may have delayed medical care out of fear of acquiring COVID-19. Anecdotally, we have seen patients that are very sick on arrival, even with ruptured appendixes. In some cases, patients have waited to call 911 until they could no longer breath on their own. The collateral damage will not be known for some time; however, we can see anecdotally the impact COVID-19 has had. We do know that the Campaign for Surviving Sepsis Guidelines has positively influenced the care of these patients with COVID-19, and has led to quick identification and treatment 

As the weeks have gone by during this pandemic, we have learned to adapt. We trust we have the PPE we need. We have watched entire communities come together with donated N95 respirators and cloth masks, along with hot meals and nightly cheering for healthcare workers. It seems like everyone is breathing a bit easier now as the United States has passed the peak strain of resources on our healthcare systems. Along the way, we have learned how to care for these patients while caring for ourselves and each other.  

Looking toward the future

One of the toughest parts of dealing with this health crisis has been watching friends and colleagues that are healthcare providers become ill. According to May 2020 statistics, approximately 90,000 healthcare workers worldwide had been diagnosed with COVID-19.2 We are holding our breath for the “next wave” but I think we are better equipped to handle the illness and the emotional aspects of it.  Additionally, many providers have developed elaborate disinfecting plans to keep their families safe. 

As a sepsis coordinator, I am grateful for the sepsis community and its resources. I appreciate the virtual community and social media platforms that have empowered us all with knowledge and helped us do what we do best as coordinators which is to educate and advocate.  It is critical, now more than ever that we spread facts and not fear. I look forward to all the lessons learned as we decompress from this crisis. In the event that a second wave does occur, we will be better equipped to save lives. 

References

1. Centers for Disease C, Prevention. Estimated Influenza Illnesses, Medical visits, Hospitalizations, and Deaths in the United States — 2018–2019 influenza season https://www.cdc.gov/flu/about/burden/2018-2019.html#:~:text=Conclusion,the%202018%E2%80%932019%20influenza%20season.

2. Mantovani, C. Over 90,000 healthcare workers infected with COVID-19 worldwide: Nurses group. Reuters. https://www.reuters.com/article/us-health-coronavirus-nurses/over-90000-health-workers-infected-with-covid-19-worldwide-nurses-group-idUSKBN22I1XH

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