The Changing Face of COVID-19 Care

The Philadelphia Inquirer

In the early days of the coronavirus pandemic, doctors in Philadelphia-area hospitals, like colleagues everywhere, were learning on the fly, desperately searching for anything that might help critically ill patients. They were quick to put patients on ventilators and try drugs that had shown even a hint of effectiveness in small studies in China. They called friends in Europe, West Coast hospitals, or New York, where the virus hit a little earlier, in search of anecdotal evidence that anything could stem the tide of death.

"People were just throwing anything they could at it," said Debra Powell, chief of infectious diseases at Reading Hospital-Tower Health.

When a ventilator wasn't enough, this coronavirus patient went on ECMO. It was not a sure thing.

"Early on, practices were definitely variable, from center to center, physician to physician, and floor to floor," said Keith Hamilton, an infectious-diseases specialist at the Hospital of the University of Pennsylvania.

Now that they have more than six months' experience with the new virus, doctors at hospitals throughout the region have settled on a core set of treatments known to help fight the disease, although none is a cure. Doctors have made "countless small changes" in the way they treat the disease, said Jonathan Gleason, chief quality officer for Jefferson Health. Testing and protective gear are more widely available.

"I think that there's a lot less panic," said Gerard Criner, chair of thoracic medicine and surgery and director of the Temple Lung Center. "That doesn't sound like much, but that's huge."

There are still treatment differences that might matter to patients who can choose a hospital when they have COVID-19 symptoms. Some, for example, offer clinical trials. These are, by definition, unproven treatments, but they have been a way to gain early access to treatments that later proved modestly effective, such as the antiviral drug remdesivir.

Other hospitals are trying vitamins that doctors hope might boost immune response. Some are sold on proning — placing patients on their stomachs to improve breathing — while others use it less often.

Smaller hospitals often can't provide ECMO (extracorporeal membrane oxygenation), an advanced form for breathing help for the sickest patients, but can transfer to larger facilities. Nitin Puri, codirector of critical care services at Cooper University Hospital, says the treatment has helped COVID-19 patients.

Currently, the number of patients hospitalized for COVID-19 is low. At the local peak of cases in mid-April, Penn hospitals had more than 300 patients a day, Hamilton said. In September, they averaged fewer than 30. Hospitalized cases have fallen from 225 a day to 25 at Temple and from 220 to 10 at Cooper. COVID-19 patients at Jefferson's 14 hospitals peaked at around 800 and are now 50 to 60. However, hospitals worry that cases may rise once cold weather drives people back inside where the virus spreads more easily.

While some doctors said mortality rates have fallen significantly since spring, others said comparisons are difficult. The pandemic initially hit hard among elderly patients in long-term care settings, a population that the virus is especially likely to kill. Mortality rates fall with age, and hospitalized patients now tend to be younger. Some doctors also think better testing, earlier monitoring, and much better public awareness may be leading some patients to seek care

Doctors representing a range of Philadelphia-area health systems — Cooper, Jefferson, Main Line Health, Penn, Prime Healthcare, Temple, Tower Health, and Virtua — described very similar approaches to core protocols for COVID-19 patients. While these groups usually compete, the pandemic has led to an exceptional degree of cooperation and data-sharing, the doctors said.

Because there is no cure, good treatment still rests on supportive care. Doctors say they are slower now to use breathing machines for coronavirus patients with low blood oxygen levels, because the lungs of coronavirus patients did not respond as expected to ventilation. "This is a whole new disease that we had to learn," said Eric Sztejman, medical director of the ICU at Virtua Marlton Hospital.

Doctors now try giving extra oxygen in a variety of less invasive ways before switching to a ventilator. Proning, which allows for more efficient use of diseased lungs, is also common. Some hospitals use it for almost every patient who is short of breath.

Patients also now routinely get remdesivir, a drug that is still being tested but was given emergency authorization by the U.S. Food and Drug Administration. So far, it has been shown to reduce days in the hospital but not deaths.

Patients also often receive blood plasma from COVID-19 survivors, which contains antibodies. Some doctors are more enthusiastic than others about this approach, which is still being studied. Some say results are uneven, possibly because not all plasma contains the same amount of antibodies. "We gave a ton of convalescent plasma," Puri said. "I don't know if it helped." Two Virtua patients who got plasma from the same donor had great results, Sztejman said. Others did not do as well. John Zurlo, an infectious-diseases doctor at Jefferson Health, said there's "very little" demand for plasma. He thinks its best use may be in patients very early in the disease.

These treatments are meant to improve immune response. Later in the course of the disease, an immune overreaction known as cytokine storm can cause the most serious damage. The steroid drug dexamethasone, which tamps down immune response, is now frequently given. Doctors said there is good evidence that it helps.

Doctors did not initially know that coronavirus increased blood clotting, raising the risk for tissue damage throughout the body. Now that they do, they test for signs that clots are forming. If patients score high, they are given medications that prevent blood from clumping up and clogging blood vessels.

Hydroxychloroquine, once touted as a wonder drug by President Donald Trump, has fallen into disfavor. Some doctors said Actemra (tocilizumab), an anti-inflammatory drug that many hoped would help COVID-19 patients, has also been a disappointment. Cooper has stopped using Kaletra, an HIV drug, after bad trial results. Suburban Community Hospital no longer uses the anti-parasitic drug ivermectin.

In the early weeks, new COVID-19 patients were often given antibacterial drugs because bacterial pneumonia is common with other respiratory viruses. Doctors said they rarely do that now.

Doctors at smaller community hospitals, regional medical centers, and the largest academic medical centers described the same general approach to care. This raises the question: Does it matter where you go?

Many doctors said probably not. "A lot of the management around COVID really involves a lot of things that we all have at our disposal in any health-care facility," Hamilton said.

Some at larger hospitals, though, said that experience with complex intensive-care patients and more extensive resources may make larger health systems the better choice.

"The larger academic medical centers are probably better versed on how to take care of really sick patients," Powell said.

Others, though, said there are advantages to community hospitals. Ronak Bhimeni, chief medical officer for Prime's Lower Bucks Hospital, said his patients avoided the crush some larger hospitals experienced. Lower Bucks always had adequate supplies. "There was never a time when we felt that we couldn't manage this," he said.

One clear difference is that academic medical centers are far more likely to offer clinical trials. You can search clinicaltrials.gov to see what centers near you offer. If you're the kind of person who wants to help make scientific progress and have early access to new — unproven — treatments, this may be important to you. Temple has a notably long list of trials, and Criner said more than half of the hospital's coronavirus patients have joined one. "We try to have multiple options open so we can offer multiple things to people," he said.

In general, current trials are looking at drugs with tongue-twisting names that might reduce inflammation, improve immune response, or combat cytokine storm.

"I think it's going to be a cocktail of different drugs working at different levels that's going to be most beneficial," Criner said.

Only a handful of hospitals mentioned trials for patients who aren't sick enough to be in the hospital. Temple and Jefferson are testing monoclonal antibodies in outpatients and Main Line Health plans to test colchicine, a gout drug, in that group. Penn is testing whether a nasal spray can prevent infection in health workers and is still studying hydroxychloroquine in outpatients.

If you don't want a trial, hospitals may also try drugs that are already FDA-approved for other diagnoses. A few are looking at vitamins that have been tied to immune functioning. Some patients at Lower Bucks, for example, get Vitamin C or thiamine. Main Line Health's Lankenau Institute for Medical Research plans to test Vitamin A and zinc. Sztejman at Virtua gives Vitamin D. (Low Vitamin D has been associated with worse outcomes for COVID-19 patients.) Hamilton and Powell don't think there's enough evidence to support vitamin use.

Wayne Psek, a healthcare quality expert at George Washington University's Milken Institute School of Public Health, says there are not enough data available now to know which types of hospitals are doing a better job. Experience usually is helpful, but, in this case, "we just don't know how to treat (coronavirus) well enough." Some hospitals, he said, may be better staffed and better equipped to evaluate new information, but most are sharing now. He said he would make sure hospitals had beds available.

Albert Wu, director of the Johns Hopkins Center for Health Services and Outcomes, said coronavirus patients may benefit from the extra resources and research at larger facilities. Bigger places have more people to monitor and share study results. Practice often improves care. "In general, there is a volume-outcome relationship in almost anything that's complicated," he said. Treating HIV patients reinforced the value of clinical trials for him. "Access to clinical trials is an important element of quality care when there's no agreed consensus treatment," he said. Still, he said, many smaller hospitals now have easy access to advice from academic medical centers in their networks.

You can expect treatments to continue changing as doctors wade through what Hamilton says is already an "absolutely staggering" amount of research on COVID-19.