Fewer, but sicker patients in the MGH ICUs

Transfers from other hospitals driving greater acuity

This is the eleventh conversation between Dr. Jarone Lee, a frontline critical care and emergency physician at Massachusetts General Hospital and associate professor at Harvard Medical School, and Dr. Paul Hattis, an associate professor at the Tufts University Medical School who participates in CommonWealth’s Health or Consequences Codcast. Find links for past conversations at the end of the story.

 

PAUL HATTIS: The state’s COVID-19 numbers indicate the number of ICU patients is trending down. What’s the situation at Mass General?

 JARONE LEE: Our numbers are declining – we have around 150 COVID confirmed patients admitted and around 60 in the ICU – but the patients we do have are some of the sickest we’ve seen so far.

 HATTIS: Why’s that?

 LEE: We are starting to open our hospital and we are accepting more transfers from community hospitals. Many of these transfers are not newly diagnosed COVID patients, but instead are profoundly sick patients who have been in other hospitals’ ICUs for weeks. These patients have additional complexity; many of them are failing or making no progress with a ventilator. They are often coming to us for extracorporeal membrane oxygenation or ECMO. Unlike ventilators, which help a patient breathe using a tube inserted down their throat, ECMO circulates a patient’s blood through a machine outside the body, where it is oxygenated and then returned to the body, With some COVID-19 patients, it allows the lungs to heal better from the damage caused by the virus.

HATTIS: So patients are coming to MGH for ECMO?

LEE: Yes, we do get transfers for consideration of ECMO. Many patients respond to rescue therapies that we use before ECMO, so only a small fraction of transfers end up on ECMO with us. Yet we currently have the highest number of patients on ECMO we’ve ever had, even higher than when we were at the peak of the surge. Good news is that they generally have done well. This new reality is that the patients we are treating now with COVID are sicker than we have had in the ICU since the beginning of the pandemic.  My sense is that the other ECMO referral centers in Boston, such as Brigham and Women’s, Tufts, and Beth Israel are having the same experience.

HATTIS: New state regulations will allow health care systems and independent hospitals to open up more for non-COVID care once at least 25 percent of their beds, including in the ICU, are open. After they open, 20 percent of beds have to remain unoccupied. What’s this mean for MGH?

LEE: I appreciate the amount of thought and work put into the re-opening plan for our state. The plan tries to maintain appropriate guardrails for flexibility as no one knows what is going to happen. I see the need to have enough beds in case there is another surge. The empty beds requirement will play out across entire hospital systems, so within MassGeneral Brigham we should be okay.

My worry is for the smaller, community hospitals such as Signature Health in Brockton and Lawrence General.  As they generally have fewer total resources, including ICU physicians, nurses, staff, and equipment, their ability to flex-up is limited. The new regulation mandates that they never fall below 20 percent of open beds, and as a result there could be the unintended consequence of these smaller systems needing to transfer more of their ICU patients to hospitals like mine so that they can have sufficient open bed capacity to be able to offer other services.  Reopening for certain procedures now is a financial lifeline for hospitals, and this is especially true for the smaller hospitals and systems.

HATTIS: A lot in the press this past week about a COVID-related condition called Multisystem Inflammatory Syndrome in Children. What have you seen?

LEE: Boston Children’s Hospital has reported a few cases and we have seen a few here as well.  As a primarily adult physician, I personally have not seen the disease.   But I’m not surprised this condition was reported by my pediatric colleagues.  Since the beginning of this pandemic, we have seen many adult patients with high levels of inflammation that triggers high fevers, high heart rates, and difficult-to-control blood pressures.  We treat it supportively with medications for these associated manifestations.  If the inflammation is bad enough, it can lead to injury to all the organs, including the heart, lungs, kidneys, brain, and blood vessels.  A small minority of patients with COVID-19 in our ICU have also evidenced an inflammatory response above and beyond many others, making them among the sickest we have cared for with COVID-19 disease.  Naturally, this has led to many ongoing studies to see if drugs that reduce inflammation can improve outcomes.  While treating patients in a high inflammatory state is not something new to us, we hope that we can find some effective treatments for this condition. It remains an area of clinical challenge.

HATTIS: Last week you mentioned a new website that you and MGH colleagues created to be a resource to other hospitals when dealing with sick COVID patients. What’s new with that?

LEE: We created the COVID-19 Urgent Resource Video Education or CURVE website. CURVE started as a grassroots project where a few of us from multiple departments wanted to create a succinct, video-based education platform on COVID-19 to help front-line healthcare providers that need additional COVID-19 education.   We knew that every hospital has different needs, so we have both long, deep-dive videos into topics as well as shorter condensed videos for quick highlights.  We cover topics relevant to caring for sick COVID-19 patients, including those on ventilators in the ICU.  We also have short procedural videos on how to do certain tasks, such as proning a patient that will be of particular interest to nursing staff. The current website is just version 1.0.  We wanted to get something up and running fast. Our plan is to regularly update and add content. We welcome comments and suggestions.

HATTIS: Moderna seems to be making progress with the vaccine it is attempting to develop.

LEE: This is great news and hopeful.  As a clinician and scientist, I am cautiously optimistic as the information released was only in the form of a press release on partial results from a phase 1 trial. The company reports that there were neutralizing antibodies in 8 of the 45 patients in the trial, which is barely 17 percent. It seems data continue to come out on small cohorts that seem hopeful but could be extremely misleading and potentially dangerous. This is the same story for remdesivir, as we only have a press release and we are still awaiting the trial data and results after weeks of waiting. From a scientific point of view, we await the official publications with more data in order to better judge the value of these medicines and vaccines.

HATTIS: Last week we talked about our mentor, Bob Sigmond, who often talked about the need for a more collaborative spirit  among nonprofit hospitals—even in a world of competition. He once served on the board of a health system where a plane crash prompted competing hospitals to work together in ways that they never had before.  He also noted how short-lived that collaborative spirit was; and that it had disappeared about a month after the crash. Do you think the cooperation you have witnessed among hospitals here in Boston during this first phase of the pandemic will last?

LEE: Bob always taught us through stories from his personal experience.  During this pandemic, the immense collaboration both in and outside the hospital is nothing that I’ve ever seen or participated in. It does show that we all can come together in moments of real challenge, whether it’s sharing ventilators or limited supplies of remdesivir. I hope that many of the relationships and communication mechanisms built during this time will continue, but, like Bob’s experience, I worry that history suggests we are more likely to return to the maladaptive and competitive world that seems to be pervasive in our US healthcare system.

My hope goes beyond clinicians. I’ve heard that many primary care practices in Massachusetts, who operate with minimal financial reserves, are financially devastated as their patient volumes have dropped. If these practices close, we could create profound access-to-care issues and my guess is that more patients will either delay care or be required to seek care in more expensive settings, such as emergency departments.  Either way, this is bad for the health of our patients and community.

There must be a way for our governmental leaders, in conjunction with the know-how of our health insurers to develop a solution that will maintain our primary care system.  This is something that Sigmond, who often worked bringing providers and insurers together, would really jump on if he was still with us.

HATTIS: If a second surge comes this summer as a result of opening up, what worry would you have from a care perspective?

LEE: If a second surge does hit us, I truly believe that it could be worse, especially if it comes sooner as preventive measures are lifted.  It might not be that we will have more patients as compared to the first surge, but we may be in a worse position resource-wise. We are still very busy with a high-volume of ill patients with COVID-19.  Many of them are still on ventilators and will probably require a ventilator for some time after discharge. So, once they are over their acute illness, they would need to go to a rehab facility that can support ventilators. With a second surge, we will not only need many ventilators in rehab facilities, but we will also need ventilators in our hospitals.  Now apply this same line of thinking to all the other supplies and drugs needed to take care of COVID patients. We might not have enough

HATTIS: Anything new on the personal side?

LEE: I am very concerned about the increasing anti-Asian and particularly anti-Chinese sentiment that is growing in our society. This is especially difficult to hear and see as many of our front-line health care and essential workers are of Asian descent – delivery and grocery store workers, janitorial staff, nurses, physicians—really in a wide variety of roles. It is disheartening to witness and hear hateful and prejudicial comments when everyone is trying to work together and collaborate to get through this crisis. I believe there needs to be leadership from the highest levels of government and other organizations to address this issue. This means supporting and not marginalizing our Asian-American, front-line, essential workers, including myself.

 

Previous conversations with Dr. Lee:

The Codcast: A report from the frontlines at MGH

Q &A with MGH doc Jarone Lee: We’re seeing patients of all ages

Dr. Lee: Preparing for the surge

Dr. Lee: ICU units won’t beat this disease

Dr. Lee: At MGH patients don’t die alone

Surge still manageable for Dr. Lee

Dr. Lee: We’re busy but in good shape

Dr. Lee says COVID-19 patient counts down

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
I’m seeing promising ventilator death data

At MGH, they worry about a second surge