How Rapidly Did Hospitals Adopt COVID-19 Recommended Procedures?

Hospitals and other healthcare facilities are notoriously slow to adopt new treatments or practices, with one study estimating this time lag to be as great as 17 years. However, the outbreak of the highly infectious COVID-19 respiratory virus called for new standard operating procedures to be implemented immediately.

A new study, published today in JAMA, sought to assess the rapidity and fidelity with which academic medical centers adopted COVID-19 procedural evidence into practice. The survey study was co-led by Thomas Jefferson University and the University of California, San Francisco (UCSF).

“Given the singular focus on COVID-19, we were interested to see how nimble hospitals were able to shift care based on rapidly changing, and sometimes conflicting, evidence,” said Alan Kubey, MD, a co-leader of the study and a specialist in hospital medicine at Jefferson Health and Mayo Clinic.

Investigators collected data from over 50 academic medical centers, surveying members of the Hospital Medicine Reengineering Network from December 17, 2020-February 10, 2021. Survey responses were compared to institutional recommendations of COVID-19 management, as informed by evidence gathered from randomized clinical trials.

A total of 52 of the 83 contacted hospitals responded and consented to the study. Of these, 94% (n=49) self-identified as academic medical centers, while the remaining 6% identified as AMC-affiliated teaching hospitals. 98% (n=51) of sites had internal COVID-19 pandemic management guidance, and 94% (n=48) of these had their guidance generated by multidisciplinary committees.

Of the 51 healthcare sites with internal COVID-19 procedural guidance, these recommendations were communicated primarily through email (43 sites; 84%) and/or institutional websites (42 sites; 82%).

There were some significant changes to hospital operations caused due to the COVID-19 pandemic. These included 94-100% of surveyed sites recommending dexamethasone for patients who required at least 4 L of oxygen, and 81% recommending dexamethasone for patients requiring 1-2 L of oxygen. Other procedural changes included 69% recommending remdesivir for patients requiring mechanical ventilation, 35% only using remdesivir during “early or viral” stage of COVID-19 illness, 67% implementing awake proning, and17% recommending D-dimer-based therapeutic anticoagulation.

The study authors reported being surprised by the rapidity and near-universality with which certain measures, like administering dexamethasone to patients requiring oxygen, were adopted. In the 6-8 months after a randomized clinical trial found dexamethasone improved COVID-19 outcomes, 94-100% of surveyed hospitals were administering the therapy to patients who required at least 4 L of oxygen.

“We were all learning in real-time and there was a resolve to collaborate,” explained study co-lead Amy Chang Berger, MD, PhD, of UCSF. “Hospitals were sharing protocols online, huge amounts of data were coming in almost daily in peer-reviewed journals and pre-print servers, and many doctors were also detailing their experiences on social media.”

The investigators found that healthcare institutions typically favored treatment over no treatment, which they attributed to systemic pressures to do something rather than nothing. The AMCs also exhibited their dexterity by implementing a range of COVID-19 interventions. Overall, “translation from evidence to practice guidelines was remarkably complete for interventions supported by aligned national guidelines and high-quality studies,” the study authors concluded.