Multiple patients on a single mechanical ventilator?
Recently, the notion of splitting single mechanical ventilators over multiple patients in acute respiratory failure has come to the forefront, especially as New York City may run out of ventilators as soon as April 1st. The Society of Critical Care Medicine led a consortium of groups in developing a consensus statement addressing the concept, released on March 26, 2020. The article recommends against using a single mechanical ventilator for multiple patients. Some of the reasons include variability of patients’ lung needs (i.e., each patient may require unique volumes of air and different amounts of oxygen; splitting ventilators only works when all of the patients sharing the machine can safely have the same parameters. Other concerns relate to engineering: currently, mechanical ventilators are designed to monitor one patient at a time; This means that various alarms might be inaccurate, and difficult to interpret. These limitations, however, can be overcome in some cases. For example Columbia-New York Presbyterian Hospital has come up with workarounds to many of the issues listed in the consensus statement. Suggestions include keeping all patients temporarily paralyzed so that sudden movements do not trigger alarms, and the changing of various alarm settings to make sure that physicians and respiratory therapists are only made aware of serious problems. Given New York City’s trajectory in the covid-19 pandemic, the need to maintain multiple patients on a single mechanical ventilator may soon become a reality.
More estimates of the case-fatality rate (CFR) of covid-19
In a new study published in Lancet Infectious Disease, researchers used data from China and outside of China from the start of the pandemic through February 8th to estimate the fatality rate of covid-19. Investigators used sophisticated statistical models to estimate an adjusted CFR of approximately 1.38 percent. Notably, the CFR increased with age with a CFR of 0.32 percent in patients under 60 years old and a CFR of 6.4 percent in patients older 60 years old. Patients aged 80 year and older had an estimated CFR of 13.4 percent. What does this mean? These data add to the growing literature suggesting that the CFR of covid-19 is lower than original estimates, though older patients still appear to be extremely vulnerable to the SARS-Cov-2 virus.
FDA grants emergency authorization for medication
The U.S. Food & Drug Administration (FDA) continues to respond to the global pandemic now spreading throughout the country. On Sunday, the oft-lauded but little evidenced chloroquine and hydroxychloroquine were granted Emergency Use Authorizations (EUA) for the treatment of covid-19. Bestowed by the FDA commissioner during public health emergencies related to chemical, biologic, radiological, or nuclear threats, an EUA temporarily authorizes the production or use of a medical countermeasure to strengthen public health responses. Although already approved for treating malaria, the additional EUA allows these medications to be added to the Strategic National Stockpile (SNS), a government repository of medical supplies for use in public health emergencies. With the announcement of the EUA, the FDA also announced that two pharmaceutical companies had donated millions of doses of the medication to the SNS. Nevertheless, skepticism within the medical community regarding the efficacy of these medications in the treatment of covid-19 remains, primarily due to the lack of clinical evidence in controlled trials. Concerns have also been raised that inappropriate guidance regarding the use of these medications from non-medical professionals has resulted in a shortage of these medications for those who them for treating various other medical conditions including lupus and rheumatoid arthritis. President Trump has been criticized for touting the medications, even as some of his closest advisors have publicly voiced reservations over unproven treatments. On Friday, the FDA also granted an EUA to Abbott Laboratories for the production and use of a rapid test for the detection of SARS-CoV-2. The test runs on previously produced Abbott equipment, already available in many physician offices and hospitals around the country. Abbott announced that they hope to produce 50,000 tests per week.
Changes to Medicare payment programs
Citing the need for physicians to focus on patient care during the coronavirus pandemic, The Centers for Medicare and Medicaid Services (CMS) has lowered barriers to reimbursement and expanded its pools of eligible providers. The Accelerated and Advanced Payments Program has been expanded to include more Medicare Part A providers and Part B suppliers. Eligible entities can request advance payment for services to be rendered, with established timelines to repay any balance owed to CMS after the completion of relevant treatments. These changes come in an effort to assist hospitals and community-based physicians which have expressed maintaining solvency during the pandemic without such policies would be difficult.
Joint Commission supports provider-supplied PPE
Citing the need for hospitals to conserve limited stores of personal protective equipment (PPE), the Joint Commission on Tuesday issued a statement of support for the use of commercially available respirators and/or face masks supplied by physicians and non-physician providers when such equipment cannot otherwise be supplied for certain high-risk procedures. The organization did note, however, that the use of homemade masks should be reserved for only the most dire of circumstances when no proven protective PPE is available.