Current issues and trends in Respiratory therapy

Critical Care Outreach Team During COVID-19: Ventilatory Support in the Ward and Outcomes

Antonio Messina, Andrea Pradella, Valeria Alicino, Maxim Neganov, Giacomo De Mattei, Giacomo Coppalini, Katerina Negri, Elena Costantini, Alessandro Protti, Elena Azzolini,

Michele Ciccarelli, Alessio Aghemo, Antonio Voza, Massimiliano Greco, Michele Lagioia, and Maurizio Cecconi

BACKGROUND: During the coronavirus disease 2019 (COVID-19) outbreak, a critical care out-

reach team was implemented in our hospital to guarantee multidisciplinary patient assessment at

admission and prompt ICU support in medical wards. In this paper, we report the activity plan

results and describe the baseline characteristics of the referred subjects. METHODS: We retrospec-

tively evaluated data from 125 subjects referred to the critical care outreach team from March 22 to

April 22, 2020. We considered subjects with a ceiling of care decision, with those deemed eligible

assigned to level 3 care (ward subgroup), and those deemed ineligible admitted to the ICU (ICU sub-

group). Quality indicators of the outreach team plan delivery included number of cardiac arrest calls,

number of intubations in level 2 areas, and ineffective palliative support. RESULTS: We enrolled

125 consecutive adult subjects with a confirmed diagnosis of COVID-19. We did not report any emer-

gency endotracheal intubations in the clinical ward. In the care ceiling subgroup, we had 2 (3.3%)

emergency calls for cardiac arrest, whereas signs of ineffective palliative support were reported in 5

subjects (12.5%). Noninvasive forms of respiratory assistance were delivered to 40.0% of subjects in

the ward subgroup (median 3 d [interquartile range (IQR) 2–5]), to 45.9% of subjects in the care

ceiling subgroup (median 5 d [IQR 3–7]), and to 64.7% of subjects in the ICU subgroup (median 2.5

d [IQR 1–3]). Thirty of the 31 ward subjects (96.7%), 26 of the 34 ICU subjects, (76.4%), and 19 of

the 61 ceiling of care subjects (31.1%) were discharged. CONCLUSIONS: In the context of a hospital

and ICU surge, a multidisciplinary daily plan supported by a dedicated critical care outreach team was

associated with a low rate of cardiac arrest calls, no emergency intubations in the ward, and appropri-

ate palliative care support for subjects with a ceiling of care decision. Key words: COVID-19; critical care outreach; ethics; noninvasive ventilation; intensive care; high-flow nasal cannula; continuous posi- tive airway pressure. [Respir Care 2021;66(6):928–935. © 2021 Daedalus Enterprises]

Introduction

Soon after identifying a secondary transmission cluster of

coronavirus disease 2019 (COVID-19) in the Lombardy

region of Italy on February 20, 2020, the public health author-

ities established an emergency task force to coordinate the

response plan.1,2 One of the force’s first directives was to

cohort these patients at the ward or unit level. Receiving hos-

pitals were asked to create dedicated wards and level 3 ICU

beds.1 This decision substantially impacted the surge capacity

and ward organization of Humanitas Research Hospital

(Rozzano, Milan, Lombardy, Italy), a multidisciplinary 700-

bed academic hospital primarily focused on cancer and

All authors are affiliated with Humanitas Clinical and Research Center -

IRCCS, Rozzano (Milan), Italy. Drs Messina, Protti, Aghemo, Greco,

and Cecconi are affiliated with the Department of Biomedical Sciences,

Humanitas University, Pieve Emanuele (Milan), Italy.

The authors have disclosed no conflicts of interest.

Correspondence: Antonio Messina MD PhD, Department of Anesthesia

and Intensive Care Medicine, Humanitas Clinical and Research Center –

IRCCS, Via Alessandro Manzoni 56, 20089 Rozzano, Milan, Italy. E-

mail: [email protected].

DOI: 10.4187/respcare.08743

928 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6

immune disorder care. Upon reaching the plateau of the out-

break in Italy in the second week of April 2020, 7 wards were

dedicated to high-dependence units, counting approximately

100 beds: 50 level 2 beds managed by non-ICU medical

teams equipped with multiparametric monitors, blood gas

analysis, and the capacity to deliver forms of noninvasive

ventilatory assistance to patients admitted with ARDS (ie,

CPAP, noninvasive ventilation [NIV], and high-flow nasal

cannula [HFNC]); and 50 level 3 beds dedicated to patients

with COVID-19 in dedicated ICUs staffed with a maximum

nurse:patient ratio of 1:3 and 6-h medical shifts of trained

intensivists supported by a weekly senior coordinator.3

Our ICU team’s mission, together with the hospital, was

to provide intensive care to whoever needed level 3 care.

To address both the massive influx of unstable, critically ill

patients and the limited capacity in our level 3 areas, we

decided to deliver intensive care outside of the level 3 ICU

by implementing a COVID-19 critical care outreach team

in level 2 areas.

The outreach team provided senior ICU decision support

along with clinical and logistic assistance to non-ICU

physicians and nurses, providing forms of respiratory sup-

port in the COVID-19 areas.4 The team was involved in a

daily multidisciplinary ward round, performed within 24 h

of admission, to define the goals of care with the attending

team. Finally, the team helped in the multidisciplinary deci-

sion-making process regarding end of life by individualiz-

ing each patient’s care pathway according to the predicted

benefit of ICU admission.

This primary aim of this research is to assess the efficacy

of our critical care outreach during the COVID-19 pan-

demic outbreak on the basis of the predetermined quality

indicators to monitor the delivery of the team’s plan in the

medical wards: the number of cardiac arrest calls, the num-

ber of intubations in level 2 areas prior to ICU admission,

and signs of respiratory discomfort or pain in subjects

undergoing forms of noninvasive respiratory support and

having a ceiling of care decision.

Moreover, we describe data regarding in-hospital manage-

ment of noninvasive ventilatory support forms in medical

wards along with the outcomes of patients with COVID-19

referred to our outreach team.

Methods

Patient data was retrospectively obtained from electronic

health records (Hospital, Lutech Group, Milan, Italy) of the

Humanitas Research Hospital (Rozzano, Milan, Italy) and

from the dataset of the outreach ICU team recorded on a

dedicated spreadsheet (Excel 2011, Microsoft, Redmond,

Washington) from March 22 to April 22, 2020. The local

ethics committee approved the use of these data.

For data analysis, we identified 3 subgroups of subjects

with COVID-19 referred to the outreach team: subjects

admitted to the wards with respiratory symptoms and receiv-

ing a ceiling of care decision (care ceiling subgroup); sub-

jects requiring more complex observation or intervention,

including noninvasive forms of ventilatory support and con-

sidered eligible for ICU care, if needed (ward subgroup); and

subjects admitted to the ICU within 24 h of the evaluation by

the team (ICU subgroup).

Outreach Team Implementation and Goals

During the first wave of COVID-19 in Italy (February to

May 2020), about 100 medical beds of Humanitas Research

Hospital were dedicated to suspected or confirmed COVID-

19 cases: 50 level 2 care (high-dependence unit) were

equipped with multiparametric monitors and the capacity to

deliver noninvasive ventilatory assistance to support a single

failing organ system (ie, respiratory), and 50 level 3 ICU

beds provided advanced respiratory support alone or moni-

toring and multi-organ support.3

The standard organization of the ICU team of the

Department of Anesthesia and Intensive Care of Humanitas

Research Hospital provides a specialist in anesthesia and in-

tensive care at all times for the response to urgent/emergent

calls from the emergency department and wards. Ceiling of

care decisions are usually discussed with a senior ICU con-

sultant in charge for the entire week.

QUICK LOOK

Current knowledge

Critical care outreach teams help provide prompt ICU

support to acutely ill adult patients in medical wards by

sharing critical care expertise and knowledge. The

goals of the outreach team are to ensure early recogni-

tion and effective local response to all deteriorating

critically ill adult patients in clinical wards.

What this paper contributes to our knowledge

In the context of hospital and ICU surge due to the

increase in COVID-19 cases, our critical care outreach

team provided ventilatory assistance to subjects in medi-

cal wards by adopting a semi-quantitative and straightfor-

ward protocol to standardize medical data reporting for

all referred patients. Outreach team support allowed for

proper allocation of ICU resources based on the analysis

of quality indicators in the medical wards (ie, number of

cardiac arrest calls and number of emergency intuba-

tions). The team was involved in individualizing goals of

care for every subject with COVID-19 admitted to medi-

cal wards, escalating their support and transferring them

to the ICU when necessary or providing effective pallia-

tive care to those with a ceiling of care decision.

CRITICAL CARE OUTREACH DURING COVID-19

RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 929

Due to the increasing number of COVID-19 hospital

admissions in the first few weeks of the outbreak, the deci-

sion was made to increase critical care support outside the

ICU by implementing a specific COVID-19 critical care

outreach team on March 22, 2020. The department staffed

the team with 2 senior consultants in charge during a day

shift (8:00 AM to 8:00 PM) and alternately on-call during the

night. This team aimed to ensure constant ICU support to

those wards staffed with nurses and doctors who were relo-

cated from their usual workplaces and lacked specific train-

ing to manage noninvasive forms of ventilatory support (ie,

CPAP, NIV, and HFNC).

According to the available literature, we identified several

quality indicators to monitor our team’s delivery of care in the

medical wards, including the number of cardiac arrest calls

from COVID-19 medical wards and the number of emer-

gency intubations in level 2 areas prior to ICU admission.5

Moreover, we assessed potentially ineffective or insufficient

palliative support plans in the subgroup of patients classif-

ied as care ceiling and undergoing forms of noninvasive respi-

ratory support in the wards by considering the signs of respira-

tory discomfort or pain reported in the medical record.5

Ventilatory Assistance

The outreach team implemented a protocol for level 2

wards to standardize medical reports. This protocol aimed

to provide simple and semi-quantitative data reporting of

all the patients referred to the critical care outreach team

by nurses and doctors with limited or no specific training

in the management of patients with ARDS. We defined 3

different settings of support: protocol A (helmet CPAP

with PEEP $ 10 cm H2O with FIO2 $ 0.5 or NIV deliv- ered via face mask), protocol B (helmet CPAP with PEEP

< 10 cm H2O or FIO2 < 0.5, or HFNC), and protocol C (air-entrainment mask with FIO2 0.5–0.6 or mask with res-

ervoir of 12–15 L/min) (Fig. 1).

The daily ward round was focused on evaluating the pa-

rameters reported in the protocol steps and comparing them

with the previous day. The decision to escalate the level of

support (ie, from C to B or from B to A) was based primarily

on the occurrence of signs and symptoms of respiratory dis-

tress, as indicated by a modified Borg scale > 3 points6 or a worsening 15-count breathless score,7 avoiding unnecessary

blood gas samples if not needed.

All of the subjects who received forms of noninvasive

ventilatory support were referred to the critical care outreach

team and treated according to predefined goals of care bun-

dles: (1) a senior consultant review within 24 h of admission

to the emergency department to establish and agree on the

goals of care with subjects, family, and attending teams; (2)

all subjects included in protocol A and protocol B received a

daily bedside assessment in the morning and another clinical

review with the attending ward physicians in the evening to

Protocol A Protocol B Protocol C CPAP PEEP ≥ 10 cm H2O and FIO2

≥ 0.5 or NIV

1 ABG per day in the morning MBS (0-10) RF (number of breaths in 15 s multiplied by 4) Observe respiratory mechanics and use of accessory muscles. 15-count breathlessness score (highest number reached before catching his/her breath)

CPAP PEEP < 10 cm H2O and FIO2 < 0.5 or HFNC

MBS (0-10) RF (number of breaths in 15 s multiplied by 4) Observe respiratory mechanics and use of accessory muscles. 15-count breathlessness score (highest number reached before catching his/her breath)

Venturi mask FIO2 0.5-0.6

or Reservioir mask 12-15 L/min

MBS (0-10) RF (number of breaths in 15 s multiplied by 4) Observe respiratory mechanics and use of accessory muscles.

Additional ABG control only if:

Acute dyspnea/agitation

Appearance of peripheral skin mottling

Desaturation > 5% compared to previous control

Position NGT in all patients treated with CPAP/NIV

lsolyte/ringers lactate up to 200 mL/day (unless contraindicated

by physician)

Anti-thrombotic prophylaxis

Gastric protection

IV of subcutaneous morphine when needed (unless

contraindicated by physician)

Modified Borg scale for dyspnea

0

� �

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

� 1 2 3 4 5 6 7 8 9 10

Nothing Very slight Slight Moderate Severe Very severe Maximum

Fig. 1. COVID-19 ventilator support escalation/de-escalation protocol. The 3 different noninvasive respiratory support protocols adopted in the wards for the daily assessment of COVID-19 subjects. The critical care outreach team recorded the Respiratory Distress Observation Scale to quantify patient respiratory distress in the ward. ABG ¼ arterial blood gas analysis; MBS ¼ modified Borg scale; RF ¼ respiratory frequency; NGT ¼ nasogastric tube; NIV ¼ noninvasive ventilation; HFNC ¼ high-flow nasal cannula.

CRITICAL CARE OUTREACH DURING COVID-19

930 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6

optimize the availability of personal protective equipment

and to evaluate the need for escalation of care up to level 3

areas or weaning from noninvasive respiratory support.

Helmet CPAP, face mask NIV, and HFNC were deliv-

ered continuously for the first 48 h from admission, unless

not tolerated. The de-escalation plan was titrated daily;

however, subjects received respiratory support cycles of at

least 12 h/d. The team reported the Respiratory Distress

Observation Scale (RDOS), a surrogate for self-reported

dyspnea previously assessed in palliative care,8,9 to quantify

patient respiratory distress in the ward.

Ceiling of Care Decision-Making Process

During the considered period, the plan for escalation to

level 3 care was shared among the ward’s senior consultants,

the critical care outreach team, and those in charge of the

COVID-19 ICU area.10,11 We proposed and discussed an

individualized ceiling of care decision-making process that

involved patient wishes, the clinical frailty scale, past medi-

cal history, and the Sequential Organ Failure Assessment

(SOFA) score at admission. Level 3 bed capacity and satura-

tion were not considered a limiting factor in considering ICU

admission. Clinical frailty score and past medical history

were assessed by interviewing the patient or the nearest fam-

ily member by telephone. Subjects with a ceiling of care de-

cision received all the medical and respiratory support

required. If appropriate, subjects were reviewed and end-of-

life care pathways were started in cases of clinical deteriora-

tion under maximum support.

Statistical Analysis and Outcome Definitions

Normal distribution of continuous variables was evaluated

using the d’Agostino-Pearson test; because some data failed

the normality test, results are expressed as median (interquar-

tile range [IQR]). Dichotomous or categorical variables were

compared using the chi-square test to compare proportions,

whereas continuous variables were compared using one-way

analysis of variance on ranks. The Kruskal-Wallis test or

Fisher exact test, as appropriate, were applied for between-

group comparisons. In-hospital outcomes (ie, death, still in

hospital, discharged either to home or rehabilitation facility)

were considered upon follow-up at 15 d from the end of the

observation period (April 22).

A multiple logistic regression analysis was performed, and

the odds ratios with 95% CI are reported, introducing the de-

cision of ceiling of care (yes/no) as the dependent variable

and including in the model the following variables, selected a

priori: PaO2=FIO2, frailty score, 12,13 Charlson comorbidity

index,14 SOFA score,15 body mass index, age, and RDOS.

Statistical analyses were conducted using GraphPad

PRISM 8 (GraphPad Software, San Diego, California). A P value of < .05 was considered statistically significant.

Results

From March 22 to April 22, 2020, 125 consecutive adult

subjects with a confirmed diagnosis of COVID-19 (ie, a me-

dian of 25% [IQR 21–27%] of the overall number of

COVID-19 positive patients admitted to the Humanitas

Research Hospital) were referred to the critical care outreach

team (Fig. 2). Of these, 61 subjects (48.8%) were in the care

ceiling subgroup, 30 subjects were in the ward subgroup, and

34 subjects were in the ICU subgroup. Concomitantly, we

recorded 25 ICU admissions in our hospital coordinated by

the COVID-19 Lombardy network, and no patient was trans-

ferred to another hospital due to saturation of level 3 areas.

Demographic characteristics, comorbidities, risk scores, and

respiratory variables of subjects are reported in Table 1. As

shown, age (P <.001), clinical frailty score (P < .001), SOFA score (P < .001), and Charlson comorbidity index (P < .001) were all significantly higher, whereas body mass index (P ¼ .002) was significantly lower, in the care ceiling subgroup, as

compared to the others. Subjects in the ward had a higher

PaO2=FIO2 than those in the care ceiling group (P ¼ .001) and a lower RDOS score compared to both the care ceiling group

and the ICU group (P < .001 and P ¼ .03, respectively).

Quality Indicators

All 34 subjects in the ICU subgroup were planned admis-

sions in level 3 areas, implying that no life-threatening

emergency endotracheal intubation in the ward. During the

last 24 h before the subject’s death in the care ceiling group,

the number of inappropriate emergency calls for cardiac

arrest was 2 (3.3%), whereas signs of respiratory discomfort

or pain were recorded in 5 subjects (12.5%). Overall, 40

subjects in the care ceiling group (65.5%) received pharma-

cologic support during the disease’s final phases.

Noninvasive Respiratory Support in the Wards

The median number of subjects receiving noninvasive

respiratory support in the wards (including either helmet

CPAP or NIV delivered by face mask or HFNC) was 9

(IQR 4–16) (Fig. 3), with a maximum of 19 subjects on

March 28, 2020. Specifically, noninvasive forms of respira-

tory assistance were delivered to 12 of 30 subjects in the

ward subgroup (40.0%; median of 3 d [IQR 2–5]), to 28 of

61 subjects in the care ceiling subgroup (45.9%; median of

5 d [IQR 3–7]), and to 22 of 34 subjects in the ICU sub-

group (64.7%; median of 2.5 d [IQR 1–3]).

Outcomes

By the end of the follow-up, 19 subjects in the care ceil-

ing subgroup (31.1%), 29 subjects in the ward subgroup

(96.7%), and 26 subjects in the ICU subgroup (76.4%)

CRITICAL CARE OUTREACH DURING COVID-19

RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 931

were discharged home or to rehabilitation facilities.

Moreover, 41 of 61 subjects in the care ceiling subgroup

(67.2%) died in the hospital as compared to none in the

ward and ICU groups (P < .001) (Table 2).

Ceiling of Care Decisions and End-of-Life Treatment

Disagreements between the ICU consultants regarding

level 3 area escalation were reported in 2 cases (4.6%), both

of which resulted in ICU admission. Subjects receiving a

ceiling of care decision had higher frailty scores (odds ratio

168.10 [95% CI 10.86–22,466.28], P < .01) and Charlson comorbidity index (odds ratio 5.97 [95% CI 2.00–34.43],

P < .01), whereas the other considered variables did not have statistical relevance: SOFA score (P ¼ .07), age (P ¼ .10), body mass index (P ¼ .50), and RDOS (P ¼ .10).

Discussion

In the context of increasing ICU and hospital surge

capacity for the COVID-19 outbreak, the institution of a spe-

cific COVID-19 outreach team helped provide appropriate

ICU care and expertise. Consequently, we did not report any

unplanned ICU admissions nor emergent unplanned

intubations in the ward. Moreover, we reported a low rate of

inappropriate emergency calls for cardiac arrest or inappropri-

ate palliative support in subjects with ceiling of care decisions.

The COVID-19 outbreak severely affected the Lombardy

region, leading to the substantial risk of overwhelming the

health care infrastructure, especially ICUs.1,2 The response

plan to a massive influx of patients was primarily based on

delivering the appropriate level of care from the emergency

department to the ICU. However, the literature does not pro-

vide recommendations in balancing surge capacity and alloca-

tion of limited resources.17

We focused our efforts on a few significant priorities to

optimize the daily plan for escalation/de-escalation support

for patients with COVID-19: (1) to individualize goals of

care for each patient admitted to clinical wards staffed with

doctors and nurses with different level of expertise; (2) to

ensure quick ICU admission for those potentially deterio-

rating ward patients; (3) to minimize the number of unex-

pected or emergent decisions to be made in the wards,

which are known to be associated with high rates of compli-

cations.18 In fact, in a context of a massive influx of

patients, an emergency call for cardiac arrest could be

related to ineffective goals of a care plan leading to either a

delay of treatment of patients potentially eligible for the

400

300

200

100

0

40

30

20

10

0

April 22, 2020

March 22, 2020

Days of observation

% referred to outreach team Overall Outreach team ICU

S ub

je ct

s (n

) Subjects (% )

Fig. 2. Critical care outreach team day-by-day workload in the considered period (March 22 to April 22, 2020). Shown are the overall number of COVID-19 positive subjects, the number of COVID-19 positive subjects referred to the outreach team, and COVID-19 positive subjects present

in ICU. Superimposed triangles represent the percentage of subjects referred to the outreach team.

CRITICAL CARE OUTREACH DURING COVID-19

932 RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6

ICU or an inaccurate multidisciplinary palliative pathway

for those who are not.

The first priority was achieved by simplifying the daily

ward reports (Fig. 1), facilitating a daily senior ICU review

of a median of 9 (IQR 4–16) subjects undergoing forms of

noninvasive respiratory support, the failure of which is

known to be associated with a poor outcome as compared to

those receiving intubation as the first choice.19 In our hospi-

tal, 25% of all COVID-19 positive admitted patients were

referred to our critical care outreach team, which provided

noninvasive respiratory support in the wards to a median of

9 patients (IQR 4–16), with a maximum of 19 patients.

The ceiling of care decision plan established after a multidis-

ciplinary approach5 is crucial to select the appropriateness of

escalation of care levels, which is, unfortunately, often not ques-

tioned until patients become critically ill, requiring intervention

by the critical care outreach team.20 Interestingly, the subjects’

age did not impact this decision as much as the clinical frailty

and Charlson comorbidity scores. Interest regarding the clinical

frailty score has grown over the past 10 years, primarily because

its assessment shows a good overall level agreement between

health care providers.12,13 Using a quantitative approach for the

patient’s global frailty may be useful when physicians with dif-

ferent levels of expertise approach a complex clinical scenario,

trying to balance the potential beneficial effect of escalating

ventilatory support with the allocation of limited resources.

Interestingly, baseline features of the ward and ICU subgroups

were comparable overall, except for the median RDOS score,

which was significantly lower in the ward subgroup (Table 1).

Since both of these subgroups presented with moderate to

severe ARDS (PaO2=FIO2< 150 mm Hg), the choice of the out- reach team seems to have been mostly related to the clinical

bedside assessment of the patient.21,22

The mortality of mechanically ventilated subjects with

COVID-19 is remarkably high, being reported between 56%

and 97% among different case series all over the world.16,23-26

So far, what is unclear is whether a trial of noninvasive sup-

port in the ward is reasonable and appropriate. The Surviving

Sepsis Campaign guidelines on the management of patients

with COVID-19 in the ICU27 suggest HFNC as a first-choice

treatment after conventional oxygen therapy failure, and an

NIV trial only if HFNC is not available. On the contrary, NHS

England recommends CPAP as the preferred form of noninva-

sive support and doesn’t suggest using HFNC because of a

lack of efficacy (https://www.england.nhs.uk/coronavirus;

Accessed March 26, 2020). Rather than suggesting one form

of ventilatory support over another, we focused on the stand-

ardization of ward procedures, considering the staff’s hetero-

geneous expertise and device availability.

The ceiling of care indication was adopted for 48.8% of the

referred subjects. The agreement with all the attending

Table 1. Subject Characteristics

Total

(N ¼ 125) Ceiling of care

(n ¼ 61) Ward

(n ¼ 30) ICU

(n ¼ 34) P

Age, y 70 (61–76) 76 (70–81)‡ 62 (54–68) 61 (56–70) < .001

Male 91 (72.8) 43 (70.5) 21 (70.0) 27 (79.4) .59

Body mass index, kg/m2 26 (24–30) 25 (23–27)§ 28 (26–30) 28 (25–35) .002

SOFA score 3 (2–5) 4 (3–6)‡ 2 (2–3) 2 (2–3) < .001

Clinical frailty score 3 (2–5) 5 (4–6)‡ 2 (2–3) 2 (2–3) < .001

Charlson comorbidity score 4 (2–5) 6 (4–7)‡ 2 (1–3) 2 (1–3) < .001

Respiratory Distress Observation Scale 5 (2–6) 5 (3–7) 3 (1–5) 5 (3–6) .005

Shock* 10 (12.5) 7 (11.5) 0 (0.0) 3 (8.8) .16

Days before admission† 5 (2–7) 3 (1–7)††,‡‡ 6 (3–10) 7 (4–8) .002

pH 7.46 (7.43–7.50) 7.46 (7.43–7.50) 7.48 (7.45–7.50) 7.48 (7.44–7.50) .68

PaO2 =FIO2 118 (87–175) 105 (77–160) 144 (118–198) ** 112 (80–183) .01

PCO2 , mm Hg 36 (33–40) 35 (31–43) 38 (34–40) 38 (33–40) .74

Lactate, mmol/L 1.1 (0.8–1.3) 1.2 (0.9–1.5) 1.0 (0.8–1.2) 1.0 (0.8–1.2) .07

Breathing frequency, breaths/min 25 (20–29) 25 (22–30) 23 (20–25) 26 (22–30) .056

Values are presented as median (interquartile range) or n (%). P values refer to subgroup comparisons. Clinical features refer to the arterial blood gas sample and clinical examination obtained at the

moment of the outreach team evaluation in the ward.

* Shock was defined as the presence of one of (1) arterial hypotension (defined as systolic blood pressure < 90 mm Hg or mean arterial pressure < 65 mm Hg) or the need for vasopressors to keep the

pressures above the predefined limits; or (2) lactate > 2 mmol/L, capillary refill time > 3 s, or widespread skin mottling.16

† Days before admission are calculated considered the day of symptoms onset reported by the subject or by the emergency team referring the subject to the emergency department.

‡ P < .001 compared to the other groups § P ¼ .01 compared to the other groups ** P ¼ .001 compared to ceiling of care †† P ¼ .02 compared to ward ‡‡ P ¼ .004 compared to ICU SOFA ¼ Sequential Organ Failure Assessment

CRITICAL CARE OUTREACH DURING COVID-19

RESPIRATORY CARE � JUNE 2021 VOL 66 NO 6 933

medical staff led to minimal incorrect emergency calls for car-

diac arrest (3.3%) in the care ceiling subgroup, for whom end-

stage comfort was achieved in the vast majority of cases

(87.5%). Despite the expected highest mortality rate in this

group, 31.1% of the subjects were discharged from the hospi-

tal, which could be considered a reasonably positive outcome.

Limitations of the Study

Several limitations of this study should be acknowl-

edged. Ward physicians drove the decision to refer a patient

to the critical care outreach team. For this reason, the selec-

tion of the subjects could potentially be biased by the triage

performed by the attending ward staff.

Our data’s reproducibility is affected by the relatively small

sample of subjects included and by the particular characteris-

tics of our hospital and ICU team. Our unit has a long-stand-

ing experience in the practice of noninvasive ventilatory

support in the wards. Moreover, the availability of senior as-

sistance from ICU consultants around the clock, providing

clinical bedside support up to twice per day, is far from being

considered the standard of care. Finally, this was only possible

by shutting down all elective activities of our hospital.

80

60

50

40

30

20

10

0

CPAP / NIV HFNC

No O2

Days of observation

S ub

je ct

s (n

)

3- 3-

20 3-

4- 20

3- 5-

20 3-

6- 20

3- 7-

20 3-

8- 20

3- 9-

20

3- 10

-2 0

3- 11

-2 0

3- 12

-2 0

3- 13

-2 0

3- 14

-2 0

3- 15

-2 0

3- 16

-2 0

3- 18

-2 0

3- 19

-2 0

3- 20

-2 0

3- 21

-2 0

3- 22

-2 0

3- 23

-2 0

3- 24

-2 0

3- 25

-2 0

3- 26

-2 0

3- 27

-2 0

3- 28

-2 0

3- 29

-2 0

3- 30

-2 0

3- 31

-2 0 4-

1- 20

4- 2-

20 4-

3- 20

3- 17

-2 0

O2

Fig. 3. Overall number of subjects referred to outreach team in the considered period (March 22 to April 22, 2020), subdivided by level of respi- ratory support. NIV ¼ noninvasive ventilation; HFNC ¼ high-flow nasal cannula.

Table 2. Outcomes at 15-d Follow-Up

Outcomes Ceiling of care

(n ¼ 61) Ward

(n ¼ 30) ICU

(n ¼ 34) P

Deaths 41 (67.2)* 0 (0.0) 0 (0.0) < .001

Still in hospital 1 (1.6) 1 (3.3) 8 (23.5)*,|| < .001

Discharged 19 (31.1) 29 (96.7)†,‡ 26 (76.4) < .001

Hospital length of stay, d 11 (5–20) 15 (11–19) 27 (18–34)†,§ < .001

Values are presented as n (%) or median (interquartile range). Subjects were discharged to home

or to rehabilitation facilities. Length of hospital stay is time from day of admission to end of the

15-d follow-up period.

* P < .001 compared to the other groups † P < .001 compared to CCOTCEI subgroup ‡ P ¼ .034 compared to CCOTICU subgroup § P ¼ .002 compared to CCOTWARD subgroup || 6 subjects still in ICU

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Finally, the ICU mortality outcomes should be consid-

ered with caution because the follow-up period, which was

stopped on April 22, 2020, included 8 of 34 (23.5%) sub-

jects who were still in ICU. Presumably, these patients with

prolonged ICU stay (median 27 d [IQR 18–34]) would

have a negative in-hospital outcome.

Conclusions

In the context of a hospital and ICU surge, the implemen-

tation of a dedicated critical care outreach team to provide

ventilatory assistance in the wards was associated with

proper allocation of ICU resources, including a low rate of

cardiac arrest calls, no emergency intubations in the ward,

and an adequate level of palliative care support for subjects

with a ceiling of care decision.

REFERENCES

1. Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the

Covid-19 outbreak in Lombardy, Italy: early experience and forecast

during an emergency response. JAMA 2020;323(16):1545-1546.

2. Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A,

et al. Baseline characteristics and outcomes of 1591 patients infected

with SARS-coV-2 admitted to ICUs of the Lombardy region, Italy.

JAMA 2020;323(16):1574-1581.

3. Carenzo L, Costantini E, Greco M, Barra FL, Rendiniello V, Mainetti M,

et al. Hospital surge capacity in a tertiary emergency referral centre during

the COVID-19 outbreak in Italy. Anaesthesia 2020;75(7):928-934.

4. Ball C, Kirkby M, Williams S. Effect of the critical care outreach team on

patient survival to discharge from hospital and readmission to critical care:

non-randomised population based study. BMJ 2003;327(7422):1014.

5. Sprung CL, Truog RD, Curtis JR, Joynt GM, Baras M, Michalsen A,

et al. Seeking worldwide professional consensus on the principles of

end-of-life care for the critically ill. The consensus for worldwide end-

of-life practice for patients in intensive care units (WELPICUS) study.

Am J Respir Crit Care Med 2014;190(8):855-866.

6. Kendrick KR, Baxi SC, Smith RM. Usefulness of the modified 0–10

Borg scale in assessing the degree of dyspnea in patients with COPD

and asthma. J Emerg Nurs 2000;26(3):216-222.

7. Williams M, De Palma L, Cafarella P, Petkov J. Fifteen-count breath-

lessness score in adults with COPD. Respirology 2006;11(5):627-632.

8. Campbell ML. Psychometric testing of a respiratory distress observa-

tion scale. J Palliat Med 2008;11(1):44-50.

9. Campbell ML, Templin T, Walch J. A respiratory distress observation scale

for patients unable to self-report dyspnea. J Palliat Med 2010;13(3):285-290.

10. Wilkinson D, Truog R, Savulescu J. In favour of medical dissensus:

why we should agree to disagree about end-of-life decisions. Bioethics

2016;30(2):109-118.

11. Needham DM, Davidson J, Cohen H, Hopkins RO, Weinert C,

Wunsch H, et al. Improving long-term outcomes after discharge from

intensive care unit: report from a stakeholders’ conference. Crit Care

Med 2012;40(2):502-509.

12. Pugh RJ, Battle CE, Thorpe C, Lynch C, Williams JP, Campbell A,

et al. Reliability of frailty assessment in the critically ill: a multicentre

prospective observational study. Anaesthesia 2019;74(6):758-764.

13. Pugh RJ, Ellison A, Pye K, Subbe CP, Thorpe CM, Lone NI, et al.

Feasibility and reliability of frailty assessment in the critically ill: a

systematic review. Crit Care 2018;22(1):49.

14. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of

classifying prognostic comorbidity in longitudinal studies: develop-

ment and validation. J Chronic Dis 1987;40(5):373-383.

15. Lambden S, Laterre PF, Levy MM, Francois B. The SOFA score-de-

velopment, utility and challenges of accurate assessment in clinical tri-

als. Crit Care 2019;23(1):374.

16. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and

outcomes of critically ill patients with SARS-CoV-2 pneumonia in

Wuhan, China: a single-centered, retrospective, observational study.

Lancet Respir Med 2020;8(5):475-481.

17. Alban A, Chick SE, Dongelmans DA, Vlaar APJ, Sent D, Study Group.

ICU capacity management during the COVID-19 pandemic using a pro-

cess simulation. Intensive Care Med 2020;46(8):1624-1626.

18. Arulkumaran N, McLaren CS, Arulkumaran K, Philips BJ, Cecconi M.

An analysis of emergency tracheal intubations in critically ill patients

by critical care trainees. J Intensive Care Soc 2018;19(3):180-187.

19. Demoule A, Girou E, Richard JC, Taille S, Brochard L. Benefits and

risks of success or failure of noninvasive ventilation. Intensive Care

Med 2006;32(11):1756-1765.

20. Pattison N, O’Gara G, Wigmore T. Negotiating transitions: involve-

ment of critical care outreach teams in end-of-life decision making.

Am J Crit Care 2015;24(3):232-240.

21. Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E,

Fan E, et al. Acute respiratory distress syndrome: the Berlin Definition.

Jama 2012;307(23):2526-2533.

22. Oromendia C, Siempos II. Reclassification of acute respiratory distress

syndrome: a secondary analysis of the ARDS network trials. Ann Am

Thorac Soc 2018;15(8):998-1001.

23. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T,

Davidson KW, et al. Presenting characteristics, comorbidities, and out-

comes among 5700 patients hospitalized with COVID-19 in the New

York City area. Jama 2020;323(20):2052-2059.

24. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk

factors for mortality of adult inpatients with COVID-19 in Wuhan, China:

a retrospective cohort study. Lancet 2020;395(10229):1054-1062.

25. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al.

Characteristics and outcomes of 21 critically ill patients with COVID-

19 in Washington State. JAMA 2020;323(16):1612-1614.

26. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla

AK, et al. Covid-19 in critically ill patients in the Seattle region - case

series. N Engl J Med 2020;382(21):2012-2022.

27. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E,

et al. Surviving Sepsis Campaign: guidelines on the management of

critically ill adults with coronavirus disease 2019 (COVID-19). Crit

Care Med 2020;48(6):e440-e469.

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