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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
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• 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
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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
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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
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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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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
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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
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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
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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
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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
50% of ventilated ICU
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%
Ventilated ICU Patients
healed 3%
died
97%
Ventilated ICU Patients
CLINICAL COURSE AND RISK FACTORS FOR MORTALITY OF ADULT INPATIENTS
WITH COVID19 IN WUHAN, CHINA: A RETROSPECTIVE COHORT STUDY
191
72% of ventilated ICU
patients survived
278
3% of ventilated ICU
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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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
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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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STRUCTURED INTERVENTIONS – BOTTOM-UP INITIATIVES
• 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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STRUCTURED INTERVENTIONS – BOTTOM-UP INITIATIVES
• 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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STRUCTURED INTERVENTIONS – BOTTOM-UP INITIATIVES
• 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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STRUCTURED INTERVENTIONS – BOTTOM-UP INITIATIVES
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
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CALL CENTER: PRACTICAL MANAGEMENT, FAMILY CONTACTS
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MEDICAL STUDENTS LET PATIENTS TALK TO THEIR FAMILY
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STRUCTURED INTERVENTIONS – BOTTOM-UP INITIATIVES
• 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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STRUCTURED INTERVENTIONS – BOTTOM-UP INITIATIVES
• 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
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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.
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
0
5
10
15
20
25
30
35
40
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
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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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