We found that common temporizing measures used for patients with respiratory distress such as bilevel positive airway pressure (BiPAP) and high-flow nasal cannula oxygen don’t seem to avert this progression. One might be able to buy a little time this way, but even with these measures, these sick patients have eventually needed intubation. This contrasts with other medical conditions, such as congestive heart failure, where such interventions might be all that are needed. More recent experience suggests that ventilator-sparing strategies may have merit; this is very much a learning process. We’ve tended to avoid both BiPAP and high-flow nasal cannula because of concerns that they might increase aerosol particle formation and thus make the virus more transmissible to health care workers.

Computed tomography scan seems to be quite sensitive to coronavirus, at least in patients having moderate or severe symptoms, probably even more sensitive than the polymerase chain reaction tests that we have. However, pragmatically, it is not very useful as a screening tool for large numbers of patients due to the time needed to perform the procedure and decontaminate the scanner between uses. It may be useful in some situations when the diagnosis of coronavirus is unclear, but we’ve mostly been treating presumptively until test results come back.

Hospital Ops Tips

Our hospitals had learned some lessons from the SARS epidemic in 2003, the H1N1 epidemic in 2009, and the Ebola crisis in 2014, lessons that had been written into their disaster plans. As the scale of the crisis became apparent, the hospitals quickly implemented these plans, which greatly helped with mitigation. Because of inability to test early on, we were unable to contain the crisis in the Puget Sound region, but we did go directly into mitigation to help flatten the disease curve.

The most-effective hospitals that have responded to this have had an internal command center staffed 24 hours a day. These staffers are knowledgeable about the plan and can coordinate different service lines, ensuring that resources are being allocated where they are needed most. That’s been a critical element.

Triaging potential coronavirus patients from other visitors to the emergency department is also essential. In one hospital, we gathered all the patients with respiratory complaints in a single area of the emergency department. Because of the high level of contagiousness of coronavirus, each emergency department in our regional hospitals has had to develop its own way to implement appropriate isolation criteria. When private rooms have not been available, some hospitals have performed triage in the waiting room and had patients wait in their cars to be notified via cellphone when a room is available. Some places have also used pop-up tents outside the department to do some prescreening.