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Facing a second surge in the COVID-19 pandemic

The effect of seasons on transmission of COVID­19 is unknown; however, with an R0 of 2–3, the warm months of summer in the northern hemisphere might not necessarily reduce transmission as they do for influenza A, which typically has an R0 of around 1·1–1·5. 1

“If we’re not expecting a second wave or a mutation of this virus, then we have learned nothing” 2

Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, also said the novel coronavirus “might keep coming back” year after year, with the possibility of an effective and implemented vaccine program at least 12-18 months away.2

The seasonal cycle of respiratory viral diseases has been widely recognized for thousands of years, as annual epidemics of the common cold and influenza disease regularly predominate in the winter season in temperate regions. Moreover, epidemics caused by viruses such as severe acute respiratory syndrome coronavirus (SARS-CoV) and the newly emerging SARS-CoV-2 occur during the winter months. 1,3

Seasonal fluctuations of temperature and humidity of the inhaled air have been shown to directly affect the airway mucosal surface defense at multiple levels. 3

“There’s a possibility that the assault of the virus on our nation next winter will actually be even more difficult than the one we just went through,” Robert Redfeld, director of the Centers of Disease Control and Prevention. 2

‘The four seasonal coronaviruses do not seem to induce long-term immunity,’ said Gregory Poland, who studies the immunogenetics of vaccines at the Mayo Clinic and we are not yet at a herd immunity level. 2 “With influenza, you need herd immunity of 60% to 70%. With measles, you need about 95%. With COVID-19, it’s somewhere in the middle.” 2

Viral rebound or resurgence expected to cause a second surge due to relaxation of restrictions to boost economic turnaround.

A number of publications have looked at extrapolated models, indicating that there remains a significant risk of resurgence when interventions are lifted to mitigate economic impact.1,4,5

Adapted from Andersen RM, et al 1 a p433

Leung and colleagues modelled the potential adverse consequences of premature relaxation of interventions, and found that such a decision might lead to a second wave of infections with transmissibility exceeding 1 again. 5

In their article, Leung et al recommend close monitoring of Rt and cCFR, given the substantial risk of viral reintroduction, highlighting the need to develop strategies mitigating against a potential second wave by striking an optimal balance between health and economic protection.

Two major factors make the likelihood of a second wave of COVID-19 very high.

One is viral transmission rebound. Although the aggressive measures appear to have reduced the number of reported cases, the absence of herd immunity against COVID-19 suggests that counts could easily resurge when interventions are relaxed, as economic activities such as business, factory operations, and normal levels of social mixing such as schools, resume.  The second is escalating case importation from overseas countries as travel restrictions lift or residually infected seeds within a population. 4

Are we prepared for the next wave of critically ill patients?

The epidemic is accelerating rapidly in multiple countries, indicating shortfalls in preparedness. 5 While the epidemic is growing exponentially, the health-care system will face severe burdens.

The planned responses to potential surge of COVID-19 cases need to rapidly assess the availability of certain critical health care resources — physician supply, hospital and ICU bed capacity, and ventilator supply. Numerous modelling studies have shown that whether the R0 reduces or not, delivery systems in all states in the US would face significant challenges should COVID-19 cases surge in the coming months. 6

Although there may not be a lack of equipment, a likely second surge will create sustained demands for advanced critical care services that will generate high-acuity, high-risk workloads for ICU providers for the foreseeable future.  Federal agencies and experts are therefore flagging a potential next wave of COVID-19 that will consist of spontaneous and erratically appearing hotspots across the US. it is also clear that some robust health systems could be overwhelmed quickly by a second wave, particularly in small population base locals (reference Albany, Georgia).

Digital transformation is key in the COVID-19 pandemic

As was demonstrated in the first wave of COVID-19, the existing health care faced significant challenges managing surge environments, therefore urgent action has already been taken to fortify health care delivery with digital technologies. Although some digital technologies, such as those used for telemedicine, have existed for decades, they have had poor penetration into the market because of heavy regulation and sparse supportive payment structures.7

The COVID-19 crisis has changed this and provided the catalyst for bringing these issues to the immediate attention of healthcare providers and funders. Reimbursement for new digital services, expanded regulatory relief, and evaluation of clinical care provided by means of these technologies is currently being assessed and implemented. 7

In particular, reimbursement for tele-critical care services has recently been expanded. This has the potential to significantly impact the cost of tele-critical care by providing an active revenue base where one previously did not exist.
 

A focus on Critical Illness in COVID-19

Critical illness from COVID-19 is associated with a high risk of mortality. Reported mortality rates of ICU patients range from 38–62% (Yin Tan Hospital), while, Yang, et al reported a 28-day mortality rate of 62% in patients who required ICU care. Among patients who developed ARDS, the mortality increases further with a 74% reported 28-day mortality rate. 8

However, this high mortality was seen in many locals that were stressed without sufficient critical care resources to treat all patients.  In more adequately resources areas (Singapore), mortality was far lower.  Hence, developing capacity to manage a surge appears key in improving COVID outcomes.

Together with the threat of a worldwide pandemic and the wide spectrum of clinical severity observed with COVID-19, there is a need for early identification of patients at higher risk of critical illness, who deteriorate rapidly. 8

The risk factors and clinical characteristics of ARDS from COVID-19 are still uncertain. ARDS and critical illness appear to develop most commonly between 1–2 weeks after the onset of symptoms, with the median age of patients requiring ICU admission between 63–66 years, and patients with older age, presence of comorbidities (cardiovascular and cerebrovascular diseases), and dyspnea, appearing to have worse outcomes. 8

Neutrophilia, hypoalbuminemia, elevated levels of lactate dehydrogenase (LDH) and D-dimer have been identified as markers of critical illness in COVID-19. However, whether the degree of lymphopenia or LDH elevation can serve as early markers of disease severity or even a surrogate for disease recovery from COVID-19 is still unclear. 8

TeleICU technology that is able to provide high accuracy predictive analytics and real time early warning of patient deterioration is already developed and could prove invaluable in our ongoing battle of the critically ill COVID-19 patients.  Such technologies enable earlier intervention, provide time to don appropriate PPE prior to procedures, and reduce stress on vital manpower necessary to maintain the adequate capacity this is associated with improved COVID-19 outcomes.

Critical issues for hospitals and TeleICU preparedness

Due to the large concern with COVID-19 cases for the potential need for ICU beds and ventilators, the telemedicine intensive care unit capacity of US hospitals remains a critical issue to address the increasing complexity of patients and insufficient supply of intensivists and overall ICU workload. As COVID-19 cases in the United States increase and as a second surge is expected, TeleICU can provide an additional layer of care, helping to ease some of the expected capacity shortfalls, provide oversite, and expedite decision making. 7

However, most hospitals are in the unfortunate position of not having existing tele ICU infrastructure. Moreover, uncertainty about whether hospitals can rapidly expand their telehealth platforms or implement a new system if they have not adopted them previously, remains a concern. Additional investment is needed, at least in regions with low telehealth adoption, to increase capacity and empower hospitals with the flexibility to plan patient care transition against the impending patient surge. 9

Health care decision makers may also need to appreciate the potential role of TeleICU that enables remote ICU care by connecting intensivists or critical care teams to hospitals with limited capacity. Expanding TeleICU capability is a key strategy throughout this pandemic, given the shortfalls of ICU beds in hospitals and the growing number of patients in need of intensive care. 7,9

TeleICU systems that are able to remotely manage a large patient population in real time, without sacrificing individual clinical needs, while at the same time protecting front line healthcare professionals from infection, are already being implemented. 10

Such programs are also able to distribute expertise to regions that have need without actively relocating active manpower.  As a surge may occur in a specific city over a period of days, attention can be focused from a remote location to that geographic area by simply changing the beds that are monitored by a TeleICU program.

Payment and regulatory structures, state licensing, credentialing across hospitals, and program implementation all take time to work through, but health systems that have already invested in telemedicine are well positioned to ensure that patients with Covid-19 receive the care they need.  10 Another positive to facilitate this rapid uptake in Telehealth is that effective from March 1, 2020 , Medicare expanded its payment for telehealth services for all Medicare beneficiaries as part of the COVID-19 Public Health Emergency. Many restrictions were thus lifted. This includes regulatory revisions and waivers in response to COVID-19 to reduce the patient and provider exposure and increase the capacity of the healthcare system. Relaxed supervision rules allow for direct supervision through real time audio-visual interaction as would be the case in a TeleICU. This may help hospitals in some way to offset the costs of TeleICU implementation. 11,12

With all of these parameters in mind, it’s time for the less prepared health systems, to ensure that they are not left behind, and to step up to the digital plate, in order to be more prepared for the next wave of critically ill COVID-19 patients.  With such services now being valued with reimbursement from CMS, what was previously economically unfeasible for many institutions is now a viable tool in critical care delivery.

References

  1. Anderson RM Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020;395L931-934.
  2. Fottrell Q. We will not have a vaccine by next winter. What happens when the coronavirus returns. Available from: https://www.marketwatch.com/story/we-will-not-have-a-vaccine-by-next-winter-what-happens-when-coronavirus-returns-2020-04-22?mod=newsviewer_click Accessed 24th April 2020
  3. Moriyama M, Hugentobler WJ, Iwasaki A. Seasonality of Respiratory Viral Infections Annu. Rev. Virol. 2020. 7:2.1–2.19
  4. Leung K, Wu JT, Leung GM.  First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment. Lancet 2020; 395: 1382–93.
  5. Xu S, Li Y. Beware of the second wave of COVID-19. Lancet 2020 April 8,2020 https://doi.org/10.1016/S0140-6736(20)30845-X Accessed 26th April 2020
  6. Radley DC, Baumgartner JC, Schneider Comparing States’ Physician, Hospital Bed, and Ventilator Supply
  7. Keesara S, Jonas A, Schulman K. Covid-19 and Health Care’s Digital Revolution. N Engl J Med 2020. Available from: https://www.nejm.org/doi/full/10.1056/NEJMp2005835  Accessed 24th April 2020
  8. Goh KJ, Choong MCM, Cheong EHT, Kalimuddin S, Wen SW, Phua GC, et al. Rapid Progression to Acute Respiratory Distress Syndrome: Review of Current Understanding of Critical Illness from COVID-19 Infection. Ann Acad Med Singapore 2020;49(3):108-118.
  9. Hong Y-R, Lawrence J, Williams D. Population-Level Interest and Telehealth Capacity of US Hospitals in Response to COVID-19: Cross-Sectional Analysis of Google Search and National Hospital Survey Data JMIR Public Health Surveill 2020;6: e18961. Available from:  http://publichealth.jmir.org/2020/2/e18961/ Accessed 24th April 2020
  10. Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med 2020. Available from: https://www.nejm.org/doi/full/10.1056/NEJMp2003539  Accessed 24th April 2020.
  11. Medicare Telemedicine Healthcare Provider FactSheet. Available from: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet   Last accessed 3rd May 2020
  12. COVID 19 Telehealth Coverage Policies. Available from: https://www.cchpca.org/resources/covid-19-telehealth-coverage-policies  Last Accessed 3rd May 2020

Patient View
Rapid, clear, consistent patient data summary and visualization

  • Patient risk stratification (high, moderate and low risk patients)
  • Intubated patients
  • Vasopressors/inotrope support
  • Empty beds
  • Key patient and unit information
  • Occupancy, ventilator status and vasoactive medication
  • User selectable vital sign display
  • Summary of all relevant lab results
    Dynamic and collaborative caregiver task list
  • Aggregate patient demographicsand PMH (past medical history) andpredicted risk level

Patient View
Rapid, clear, consistent patient data summary and visualization
High Risk Patients

  • Tasks
  • New Admissions (pulled from a left sidebar)
  • User selectable vital sign display
  • Summary of all relevant lab results
  • Dynamic and collaborative caregiver task list
  • Aggregate patient demographics, PMH and risk level

Unit View
Full TeleICU situational awareness, displaying patient data and predicted state from all units and highlighting all notifications

  • Patient risk stratification (high, moderate and low risk patients)
    Intubated patients
  • Patients on vasoactive medication
    Unit occupancy
  • Patients on vasoactive medication
  • High-level estimation of the overall unit acuity

    Key patient and unit information

     

Work List
Integration with the TeleICU workflow by gathering all notifications, tasks, new admissions and high-risk patients

  • Notifications
  • High Risk Patients
  • Tasks
  • New Admissions (pulled from a left sidebar)

Unit View by Layout

Full ICU situational awareness, displaying patient data and predicted risk level, for one unit or multiple units. The display highlights all notifications, low risk patients and other key clinical information, to provide multi-dimensional situational awareness.

  • Patient risk stratification (high, moderate and low risk patients))
  • Intubated patients
  • Vasopressors/inotrope support
  • Empty beds
  • Key patient and unit information
  • Occupancy, ventilator status and vasoactive medication
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