Michael Niederman, MD, on How COVID-19 Has Changed the Inpatient Experience

In part 2 of 3 of this video series, Pulmonology Consultant Advisory Board Member Michael Niederman, MD, from Weill Cornell Medicine, discusses the long-lasting impacts that the COVID-19 pandemic will have on the inpatient experience, including the redefinition of what an intensive care unit is. Read the full transcript.

Michael S. Niederman, MD, is associate division chief and the clinical director of the Pulmonary and Critical Care Medicine at the NewYork Presbyterian-Weill Cornell Medical Center. He is also a professor of clinical medicine at Weill Cornell Medical College.


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Michael Niederman: On the inpatient side, we’re realizing that there are many differences in how we practice medicine. Probably the most obvious difference is we've redefined what an intensive care unit is. In this surge, in this need to provide care for so many patients so quickly, we've had to redefine ICU care.

In our hospital alone in a very short period from early March to the end of May, we treated inpatient over 13,000 COVID patients, nearly 300 being mechanically ventilated. That means that many of these patients needed ICUs, and we redefined the needs of an ICU. We needed the staff. We needed the equipment. But we adopted a number of non‑traditional ICUs, not‑traditional ventilators, operating rooms. We developed multidisciplinary teams in the ICU, teams of not only pulmonary and critical care doctors, but teams that included hospitalist, surgical intensivists, anesthesiologists, cardiologists. And we’ve also incorporated onto that team a variety of residents and fellows.

And also, we developed specialized teams to assist in the ICU. For example, we had a specialized intubation team made up of nurse anesthetists and anesthesiologists. A special line team made up of surgical and radiologic proceduralists. We had physical therapists helping us with proning the patients. And so we developed a whole new concept of intensive care, where intensive care could be given, and who is part of the multi‑disciplinary team to deliver intensive care.

We’ve also learned a lot about the treatment of patients that we didn’t know before COVID. Initially, we were unsure about the value of high‑flow nasal cannula and the value about using positive‑pressure, non‑invasive ventilation. Those who were thought to possibly be dangerous, we figured out ways to use them successfully and avoid intubating patients.

We’ve also learned a lot about acute lung injury. We’ve seen a lot of the traditional stiff lung, low lung compliance, acute lung injury, ARDS. But we’ve also seen a variety of acute lung injury that appears to have normal lung compliance and may have a component of pulmonary vascular disease.

We’ve learned about some of the nonrespiratory complications to systemic complications of COVID, the coagulation problems, the cerebrovascular problems, the renal problems, the cardiovascular problems. And we’ve learned how to integrate care for multiple systems into the critical care management of each patients.

We’ve also learned valuable lessons about tracheostomy. We became much less rigid about when we did tracheostomy, and we found that tracheostomies were often necessarily delayed because of risks of aerosolization to the medical personnel. We delayed tracheostomies with no great harm to patients. But we also realized that we could liberate patients from ventilators relatively rapidly once tracheostomies were done.

We’ve learned a lot about the care of critically ill patients. We’ve learned about the management of pneumonia and the importance of course of viral pneumonia. There was certainly an awareness of this in the past, but that awareness has of course been enhanced.

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