helping empower recovery the online series (heros) · 2020. 11. 19. · ©2020 baxter healthcare...

©2020 Baxter Healthcare Corporation

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Helping Empower Recovery

The Online Series (Heros)PART 5:

90 Days Post Covid-19 –How Care Has Changed in the ICU

June 5, 2020

1GLBL/MG17/20-0021 06/2020 ©2020 Baxter Healthcare Corporation

• Support for this program is provided by Baxter International Inc.

• This program is not an accredited continuing education (CE) program

• Today’s presentation slides and on-demand viewing of this program will be available by 12-June at:

https://www.baxterglobal.com/nutrition_hero_series

Program Disclosure


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Faculty

Elisabeth De Waele, MD, PhD

Medical Director

Head of Clinical Nutrition

Critical Care Physician and Surgeon

Universitair Ziekenhuis Brussel

Brussels, Belgium


Disclosures

Elisabeth De Waele, MD, PhD

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Unrestricted Grants/Research Funding by:

Belgian Federal

Government Health

Baxter

Nutricia

KCE (Belgian Health Care

Knowledge Centre)

Fresenius

Nestlé

GLBL/MG17/20-0021 06/2020 ©2020 Baxter Healthcare Corporation

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• Address the nutritional requirements of COVID-19 patients

• Discuss the role of delivery and monitoring of nutrition support in the COVID-19 ICU patient

• Review of best practices experienced in treating COVID-19 patients

Objectives


FIRST 90 DAYS POST COVID-19:

HOW HAS CARE CHANGED IN THE ICU

Elisabeth De Waele, MD PhD

ICU – Nutrition Department

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IGLBL/MG17/20-0021 06/2020 ©2020 Baxter Healthcare Corporation

NOW IS THE TIME TO STAND STILL AND LOOK AROUND

Corona in Belgium

Coronaviruscovid19.be

Known infections Deceased

…left the

hospital

…in the

hospital

…deceased in and

outside hospital

…in ICU

2020

Number of

patients…

MAR APR MAY

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Belgian Government website, accessed 06/01/20

www.coronaviruscovid19.be


NOW IS THE TIME TO STAND STILL AND LOOK AROUND

Total Number Of Cases Deaths Healed

Admitted Versus Discharged Patients In ICUAdmitted Patients In Hospital

8Belgian Government website, accessed June 2020

www.coronaviruscovid19.be

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UNIVERSITY HOSPITAL BRUSSELS – MY WORLD

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OUTCOME OF COVID19 PATIENTS UZ BRUSSELS

79% of all COVID19 patients

admitted in UZ Brussel

are home

6% are still in the ward

15% died


Quality data ICU IZBrussels, shared with permission

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BELGIAN OUTCOME DATA

healed

49%

died

23%

on the

ward

15%

still in

ICU

11%

other hospit 2%

ICU Patients

healed

27%

died

28%

on the

ward

21%

still in

ICU

21%

other hospit 3%

Ventilated ICU Patients

healed

77%

died

11%

on the

ward

10%

other

hospit

2%

Non ICU Patients

77% of patients

admitted to ICU

survived

72% of ventilated ICU

patients survived

89% of ward

patients survived

764 278 2.969

11de standaard June 2020


healed

50%

died

50%

ICU Patients

CORONAVIRUS: NEW FIGURES ON INTENSIVE CARE

DEATHS REVEALED

healed

49%

died

23%

on the

ward

15%

still in

ICU

11%

other hospit 2%

ICU Patients

77% of patients

admitted to ICU

survived

764


patients survived

12The Guardian March 28, 2020

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healed

27%

died

28%

on the

ward

21%

still in

ICU

21%

other hospit 3%


healed 3%

died

97%


CLINICAL COURSE AND RISK FACTORS FOR MORTALITY OF ADULT INPATIENTS

WITH COVID19 IN WUHAN, CHINA: A RETROSPECTIVE COHORT STUDY

191


patients survived

278


patients survived

Fei Zhou, MD; Ting Yu, MD; Ronghui Du, MD; Guohui Fan, MS; Ying Liu, MD; Zhibo Liu, MD; Jie Xiang, MS; Yeming Wang, MD; Bin Song, MS; Xiaoying Gu, PhD; Lulu Guan, MD;

Yuan Wei, M; Hui Li, MD; Xudong Wu, MS; Jiuyang Xu, MD; Shengjin Tu, MD; Yi Zhang, MD; Prof Hua Chen, MD; Prof Bin Cao, MD

13Zhou Lancet March 9, 2020


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https://crossmark.crossref.org/dialog?doi=10.1016/S0140-6736(20)30566-3&domain=www.thelancet.com&uri_scheme=https:&cm_version=v2.0


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INTENSIVE CARE MANAGEMENT OF CORONAVIRUS DISEASE

2019 (COVID-19): CHALLENGES AND RECOMMENDATIONSJason Phua, MRCP; Li Weng, MD; Lowell Ling, MRCP; Moritoki Egi, MD; Prof Chae-Man Lim, MD; Prof Jigeeshu Vasishtha Divatia, MD; Prof Babu Raja Shrestha, MD; Prof Yaseen M Arabi, MD;

Jensen Ng, M Med Anaesthesiology; Prof Charles D Gomersall, FCICM; Prof Masaji Nishimura, MD; Prof Younsuck Koh, MD; Prof Bin Du, MD for the Asian Critical Care Clinical Trials Group

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I 16GLBL/MG17/20-0021 06/2020 ©2020 Baxter Healthcare Corporation

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https://crossmark.crossref.org/dialog?doi=10.1016/S2213-2600(20)30161-2&domain=www.thelancet.com&uri_scheme=https:&cm_version=v2.0


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I 17GLBL/MG17/20-0021 06/2020 ©2020 Baxter Healthcare Corporation Barazzoni Clin Nutr March 2020


15 MARCH 2020 FIRST PATIENTS

We Developed Our Plan March 12th

– Almost No Guidance Around

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STRUCTURED INTERVENTIONS – BOTTOM-UP INITIATIVES

Macro levelOperational

management

Communication

and staff

well being

Non-ICU

environment

(Coronary

Care Unit,

recovery room)

Internal and

external

stakeholders

contact

Medical and

organizational

command

Communication

strategies

Staff physical and

psychological well-

being

Patient’s Family

Care

Management of

ICU structure and

medical support in

remote ICUs

Head of

Department

Senior Staff

Member

Senior Staff

Member

Staff Member with

Combined Profile

Management

of non-COVID

patients

Communication

support

People

management and

training

procedures

Medical and

practical

management

Back-up Members

Crisis Unit

Confidential

Counselor

Management

Nursing

Department

Logistics,

Materials, Drugs

Senior Staff

MemberNon-medical Head Nurses

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• Report status of capacity and infrastructure

• Transmit needs to CEO, medical management, head of nursing, other hospital directors

• Prepare adaptation process of ICU: discuss with stakeholders

• Restrain non-urgent surgical procedures

• Be in contact with Belgian National Society of Intensive Care: website was activated

as a platform of information

• Daily briefing on seven building blocks

Macro level

Internal and

external

stakeholders

contact

Head of

Department


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• Treatment strategies: no non-invasive ventilation because too high viral load, remdesivir start at

day one, EN and PN in nutritional approach…

• Prepare for possible overflow and ethical decision making.

• Design COVID-specific Standard Operating Procedures (intubation)

• Choices in use of resources (Units and staff): move paediatric ICU to OR fertility department

Operational

management

Medical and

organizational

command

Senior Staff

Member

COVID-19 positieve patiëntenop IZ UZB

Opvang en behandeling


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OPTIMAL MEDICAL TREATMENT INCLUDING ECMO


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• Safety of Health Care Practitioners

• Development Communication base, the centre of ICU

• Be there: provide answers, gather questions and suggestions

• WhatsApp group with >200 members in two days:

>Reallocation of ICU units

>Report on nr of treated COVID patients

>Educational movies: how to wear protective clothes

>Recordings of daily briefings

>Practical callouts: urgent need of anti-fog for face shields

Communication

and staff

well being

Communication

strategies

Staff physical and

psychological well-

being

Patient’s Family

Care

Senior Staff

Member


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Creation of call centre

• At ICU admission communication line was opened

• Family members got medical information and kept track of their beloved ones

• After one week 8 call takers worked under supervision of 2 MDs

• Nurses and ICU MDs could focus on core business

Psychological support

• Unfavourable mental health outcomes reported in Chinese HCP exposed to COVID19 + harsh working

circumstances

• Psychologists present 2/d in coffee room, individual talks and handle panic attacks

• Breathing exercise movie

Communication

and staff

well being

Communication

strategies

Staff physical and

psychological well-

being

Patient’s Family

Care

Senior Staff

Member



CALL CENTER: PRACTICAL MANAGEMENT, FAMILY CONTACTS

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MEDICAL STUDENTS LET PATIENTS TALK TO THEIR FAMILY

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• Upgrading of Coronary Care Unit to non-COVID ICU

• Later stage: extra quarantine ICU beds

• Additional staff: cardiologists and nephrologists followed crash courses in mechanical ventilation,

inotropes and vasopressors, correct use of

protective gear

• Direct liaison with anaesthesiologists and dedicated ICU physicians

Non-ICU

environment

(Coronary

Care Unit,

recovery room)

Management of

ICU structure and

medical support in

remote ICUs

Staff Member with

Combined Profile

Management

of non-COVID

patients

Medical and

practical

management

Senior Staff

Member


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• Day and night shifts, reallocation of nurses

• Work with pharmacy, logistic department, facility care

• Creation of new logistic areas, drug management

• Communication between staff members

• Professional approach daily briefings

• Follow-up of activities of different working groups

Communication

support

Back-up Members

Crisis Unit

Confidential

Counselor

Non-medical

People

management and

training

procedures

Management

Nursing

Department

Logistics,

Materials, Drugs

Head Nurses

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FOR

ICU

Head Nurse

Head Emergency

Department

King Filip I

of BelgiumCEO, Hospital

UZ Brussels

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WHAT ABOUT NUTRITION THERAPY?

• Targets were set:

>Protein BW x 1.3g = .. g

>Calories: indirect calorimetry

• To be reached by day 3-4

• Enteral or combined with Supplemental Parenteral Nutrition

Based on ESPEN Guidelines Critically Ill Patients

NUTRITION COVID

First choice = enteral

Start prokinetics

Start at 20 ml/h until target is known

NO GASTRIC RV

PN when EN is insuff or imposs



Checklist Nutrition COVID19 Check

New patient @ ICU

Do Put feeding tube upon arrival or at time of intubation, check central line

Start feeding

Do Start tube feeding when lactate 65 even with vasopressors, muscle relaxant or prone position.

How At 20cc/h of every formula (when 2kcal/ml start at 10ml/h)

Refine and follow-up feeding

Do Get to calories (kcal/day): indirect calorimetry or provide 25x bodyweight in kg

Get to proteins (gram/day): provide 1.3x (adjust) bodyweight in kg

How Put infusion pumps of enteral/parenteral on correct speed

When enteral is not providing enough calories and proteins per day,

(nutrition in mouth, DO NOT CHECK GRV) put parenteral on top on day 4 to cover caloric and protein goal

Transition from ICU to the ward

Do Do not pull out feeding tube or central line if still needed for nutrition (normal food covers less than 60% of needs)

Communicate which kind of nutrition at what dose or follow-up yourself

How Talk to colleagues who can do which part

Stay safe

Keep track of body weight, repeat indirect calorimetry once oxygen is gone, change targets. Phosphate 400 stop PN 2 days look again and restart.

COVID19 UZBRUSSEL NUTRITION CHECKLIST BASED ON WWW.ESPEN.ORG GUIDELINES

BRUSSELS 18TH MARCH 2020 ELISABETH, JOY, CHLOE, LODE.

ESPEN GUIDELINES

Available for free at:

www.espen.org

Available at Twitter

@ElisabethWaele

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http://www.espen.org/


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WHAT ABOUT NUTRITION THERAPY?

Based on ESPEN Guidelines Critically Ill Patients

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179 READY TO USE PN BAGS IN 7 WEEKS

For >150 COVID-19 ICU patients: 1.2 bags/patient

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5

10

15

20

25

30

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Use of Parenteral Nutrition

PN SPN

16-22

March

23-29

March

30 March –

5 April

6-12

April

13-19

April

20-26

April

27 April –

3 May

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DID IT ALL PAY OFF?

Covid19 patient spend 5 weeks in ICU, different wards and now off to rehab

Patients gave consent of use of pictures 35


Our first patient leaves ICU

after intubation. Many will

follow. Good job everyone!

Patients gave consent of use of pictures

“I am hungry and thirsty.

After 5 weeks,

my first yogurt!”

Non-COVID 28-year old

ICU patient spends

3 months in ICU

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TAKE NUTRITIONAL THERAPY SERIOUSLY –

ACT ON WHAT YOU PREACH

ICU Dietitian Joy

and MD Joop :

Indirect calorometry

on COVID patients

First COVID-19

ventilated patient

leaves ICU in UZ Brussels

CEO of hospital &

Nutrition Nurse Lode

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Checklist Nutrition COVID19 Check

New patient @ ICU

Do Put feeding tube upon arrival or at time of intubation, check central line

Start feeding

Do Start tube feeding when lactate 65 even with vasopressors, muscle relaxant or prone position. How At 20cc/h of every formula (when 2kcal/ml start at 10ml/h)

Refine and follow-up feeding

Do Get to calories (kcal/day): indirect calorimetry or provide 25x bodyweight in kg Get to proteins (gram/day): provide 1.3x (adjust) bodyweight in kg

How Put infusion pumps of enteral/parenteral on correct speed

When enteral is not providing enough calories and proteins per day, (nutrition in mouth, DO NOT CHECK GRV) put parenteral on top on day 4 to cover caloric and protein goal

Transition from ICU to the ward

Do Do not pull out feeding tube or central line if still needed for nutrition (normal food covers less than 60% of needs) Communicate which kind of nutrition at what dose or follow-up yourself

How Talk to colleagues who can do which part

Stay safe

Keep track of body weight, repeat indirect calorimetry once oxygen is gone, change targets. Phosphate 400 stop PN 2 days look again and restart.

COVID19 UZBRUSSEL NUTRITION CHECKLIST BASED ON WWW.ESPEN.ORG GUIDELINES BRUSSELS 18TH MARCH 2020 ELISABETH, JOY, CHLOE, LODE.

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Thank you, Heroes!

QUESTIONS?


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Baxter is a trademark of Baxter International Inc.

Thank you to all of those

leading the fight against

COVID-19


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helping empower recovery the online series (heros) · 2020. 11. 19. · ©2020 baxter healthcare...

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