By Matt Phillion
If a year of COVID-19 could be said to have any positives, one is the immense amount of data the pandemic has generated for the healthcare industry. That data has been both vast and valuable, and resulted from a wide array of resources, including medication management solutions.
Researchers have begun to dig into the results of this data collection and identified trends that have helped them understand mortality rates during the pandemic and beyond. BD recently published two papers on specific data discoveries during COVID-19, and Kalvin Yu, MD, FIDSA, senior medical director with BD, discusses some of the key takeaways from that research.
“We try to pick topics that are germane to our end users—clinicians—but also tie it to public health,” says Yu.
Antimicrobial use during COVID-19: How much is too much?
The first of the two papers appeared in BMC Infectious Diseases, an open-access, peer-reviewed journal about all aspects of infection prevention and control. The paper dug into antimicrobial use during the pandemic, analyzing pathogens, antimicrobial use, and healthcare utilization in hospitalized U.S. patients both with and without COVID-19.
“We found that [antibiotics were] being disproportionally used for COVID patients,” says Yu.
The paper was not a new rallying cry on that topic, Yu notes; antimicrobial overuse has been a challenge in the healthcare industry for the last 20 years. “Clinicians were sounding the alarm worldwide,” he says. “Antibiotics don’t treat viruses. On the one hand, you could understand why frontline physicians were throwing antibiotics at a new virus, but what we know about the virus is that bacterial co-infection is quite low.”
Considering the rate of COVID-19 patients versus patients who were believed to have the virus but tested negative, the overuse of antimicrobials was quite high. “We were able to help educate clinicians on the fact that yes, antimicrobial overuse is occurring, and as we moved further into the pandemic, while there can be co-infections, they tend to happen later in the hospital stay,” says Yu.
The paper advocated for more targeted antimicrobial use, limiting it to patients who are not doing well or who have need of a longer hospital stay.
“The stewardship movement over the last 10 years has been [aimed at encouraging the] judicious and targeted appropriate use of antimicrobials rather than [acting as] a police force,” says Yu. “We showed in that particular paper that those who had a secondary infection had an increased risk for marked increase in hospital stays and ICU usage.”
The paper also identified that approximately 80% of COVID-19 patients did not have a detectable co-pathogen, so antimicrobial treatments should be evaluated daily and de-escalated when possible. “At the time, it was new evidence that these patients [with co-pathogens] were actually doing worse,” says Yu.
The presented data also highlighted the need for smart resource allocation and usage on a more general level. “As a former hospital administrator, I’d look at these signals to strategically budget for ICU nurses, ventilators, or certain key medications, for example. We now know this type of COVID patient stays longer, which can help with shoring up resource planning.”
With COVID-19 settling in for the long haul even with vaccines more and more available, the ability to better plan for and budget for these most resource-intensive patients will be valuable for hospital leaders now and in the future.
“Responding to a crisis like this is difficult,” says Yu. “We want to influence changes through these publications—clinicians universally understand the process of peer-reviewed journals as quality evidence generation, that they’ve gone through a process they can trust.”
A look at mortality rates during COVID-19
While the first published paper is the “downer paper,” Yu says, identifying antimicrobial overuse and the evidence that COVID-19 patients had both higher ICU use and higher risk of in-hospital death, BD was simultaneously also able to offer some positive news via its second recently published paper. Published in JAMA Network Open, this paper looked at mortality rates during the pandemic from March to November 2020.
“It showed that mortality rates across the board were decreasing,” Yu says. “Even adjusting for the fact that younger people were being admitted with the start of schools—at the time, the media was reporting a lot of schools were suspending students because of parties and gatherings—but even adjusting for younger people being hospitalized, who have a lower risk for mortality, the mortality rates were decreasing, particularly among older age groups.”
What this seemed to imply, Yu says, is that compared to the beginning of the pandemic, healthcare providers were learning how to treat COVID-19.
“There was never a golden-bullet treatment breakthrough, no big aha moment” in treating COVID-19 on the front lines, Yu says. Nevertheless, the paper showed that mortality rates were beginning to decrease—particularly in the oldest age brackets, who were expected to have higher death rates. The data demonstrated that, in general, frontline clinicians had adopted workarounds and provided better supportive care for these patients.
But what specifically was causing the numbers to go down? Much of it was a combination of lessons learned on the fly and best practices from other breathing or respiratory treatments. The media, Yu notes, picked up on the use of proning, for example—a method of turning the patient onto their stomach so they can aerate, as the position allows the patient to oxygenate more lung tissue. The technique wasn’t new, but its application was.
“I was trained on this in the 1990s for severe pneumonia, but it creates challenges when dealing with central lines or urine catheter care at the front of the body and other invasive device infection prevention considerations,” says Yu. “But in treating COVID, it appeared to have helped.”
Much of the learning was organic, Yu notes. Reports circulated that putting a patient on a ventilator too soon made it harder to wean them off, for example, something frontline clinicians became cognizant of and altered their treatment processes to accommodate. “Clinicians learned different ways of treating COVID that went against conventional wisdom for an average person with pneumonia,” he says.
Other areas of improvement included diagnosing. “There were case studies reported of people talking normally, and then upon doing an arterial blood gas test, the clinicians could see their arterial oxygenation was very low,” says Yu. “The x-ray is completely white, but the person is able to talk to the clinicians in full sentences, which belied the x-ray findings. Those learnings, and faster diagnostics, over time” made a difference.
“If they’re having changes in imaging scans and particularly if they have trouble breathing or their oxygen saturation is low, put them in a monitored bed,” says Yu.
Lessons about surge capacity
Many people don’t realize that healthcare organizations experience surge capacity issues every cold and flu season. Those in the industry, though, are well aware of that reality.
“There are times of high influx, lack of beds. Organizations live with that yearly,” says Yu. “When I was a clinician and administrator in a large integrated healthcare system, we would plan the next flu season the day after the last one ended.”
COVID-19 has helped highlight this challenge in previously unseen ways.
“One thing COVID has done is shone a spotlight on how hospitals have a problem with [cold and flu season surges],” says Yu. “We found a way to highlight the problem. The way hospitals prepare for surge capacity is going to need to be revamped.”
Most hospitals, Yu says, will look at the prior year’s census and budget for that number of patients. Sometimes, he says, nature doesn’t agree, and more ICU nurses and ventilators are needed. “COVID has changed the paradigm. Our eyes have been opened to this.”
Additionally, the triage process will need to be improved upon. “How you triage and who gets priority can be a moving target, and therefore can always be improved,” says Yu. “For sure, that is going to be a goal for hospital administrators.”
Emergency department (ED) processes will likely also be looked at based on pandemic data, Yu says. “We had a lot of people waiting for beds, and that’s not a good thing,” he says. “This really opened our eyes to what you can do in the ED.”
The data coming out of a year-plus of COVID-19 research will lead to further, more specific research in future endeavors.
“We’re seeing interesting signals we’re going to explore that involve empiric antimicrobial therapy,” says Yu. “We do think COVID will be a seasonal thing, and we’ve called that out as a future focus.”
BD has released regular newsletters with highlights on COVID-19 research throughout the brunt of the pandemic. The newsletters can be accessed on the BD website.
Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at firstname.lastname@example.org.