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Early changes in hospital resuscitation practices during the COVID-19 pandemic

Background The coronavirus disease 2019 (COVID-19) pandemic resulted in many disruptions in care for patients experiencing in-hospital cardiac arrest (IHCA). We sought to identify changes made in hospital resuscitation practices during progression of the COVID-19 pandemic. Methods We conducted a descriptive qualitative study using in-depth interviews of clinical staff leadership involved with resuscitation care at a select group of U.S. acute care hospitals in the national American Heart Association Get With The Guidelines-Resuscitation registry for IHCA. We focused interviews on resuscitation practice changes for IHCA since the initiation of the COVID-19 pandemic. We used rapid analysis techniques for qualitative data summarization and analysis. Results A total of 6 hospitals were included with interviews conducted with both physicians and nurses between November 2020 and April 2021. Three topical themes related to shifts in resuscitation practice through the COVID-19 pandemic were identified: 1) ensuring patient and provider safety and wellness (e.g., use of personal protective equipment); 2) changing protocols and training for routine educational practices (e.g., alterations in mock codes and team member roles); and 3) goals of care and end of life discussions (e.g., challenges with visitor and family policies). We found advances in leveraging technology use as an important topic that helped institutions address challenges across all 3 themes. Conclusions Early on, the COVID-19 pandemic resulted in many changes to resuscitation practices at hospitals placing an emphasis on enhanced safety, training, and end of life planning. These lessons have implications for understanding how systems may be better designed for resuscitation efforts.


Introduction
Mortality following an in-hospital cardiac arrest (IHCA) may be as high as 80 %. [1][2][3][4] The current coronavirus disease 2019 (COVID- 19) pandemic has only magnified mortality from IHCA, with both higher incidence and lower case-survival rates. 5,6 As such, healthcare systems have grappled with questions about how to treat IHCA given concerns of a highly transmissible and fatal disease. Core challenges included ensuring patient and provider safety during resuscitation practices, managing scarcity of resources and information, and leveraging potentially new technology to address these concerns. 7 In response, the American Heart Association (AHA) has revised their guidelines on care of IHCA patients and resuscitation practices, with adaptations also made by the European Resuscitation Council regarding COVID-19 guidelines. [8][9][10][11] Despite this attention, studies on how the COVID-19 pandemic has altered local resuscitation response systems have been lacking. Accordingly, we set out to understand changes made to resuscitation practices during the early COVID-19 pandemic surges at U.S. hospitals.

Methods
We conducted a descriptive qualitative study, which included indepth interviews of clinical staff at geographically and academically diverse hospitals that were included in the original Hospital Enhancement of Resuscitation Outcomes for In-Hospital Cardiac Arrest (HEROIC) study. 12 HEROIC compared resuscitation practices at top-, middle-, and bottom-performing hospitals, based on their risk standardized rates of survival to discharge for IHCA in the Get with the Guidelines-Resuscitation registry. The original study sample included hospitals with at least 20 IHCA patients from January 1, 2012 to December 31, 2014, a time period notably before the COVID-19 pandemic began. The HEROIC mixed methods study included quantitative surveys of hospital on their resuscitation practices as well as qualitative interviews at 9 hospital sites. In this study, our interviews focused on changes made to resuscitation practices with the emergence of the COVID-19 pandemic during 2020.
We approached the 9 hospitals included in the original qualitative dimension of the HEROIC study for virtual visits and 6 hospitals agreed to participate. Two hospitals declined and one never responded after repeated attempts to be contacted. Semistructured interviews with key informants at each site were conducted using an interview guide (see Appendix) developed by a diverse group of investigators with expertise and experience in qualitative research, clinical medicine, and nursing. Key informants for the interviews included individuals engaged in resuscitation systems at local institutions with roles including but not limited to Code Blue Committee Directors, Critical Care and Emergency Physicians, and Cardiopulmonary Resuscitation (CPR) Quality Coordinators, in total 10 informants were involved in the interviews across 6 sites. Table 1 lists characteristics of the interviewees. Specifically, we recruited informants who had been in their current positions prior to the onset of the COVID-19 pandemic and were able to compare IHCA resuscitations efforts prior to and during the COVID-19 pandemic at their respected institutions. For interviews, key informants met for one hour virtually with two study team members. To balance methodological and clinical expertise the interview team consisted of one clinician and one qualitative researcher. Interviews were audio and video recorded and reviewed by multiple team members (KMS, BT, PSC, BKN).
We conducted a rapid analysis of the qualitative data collected from interviews to understand changes made during the COVID-19 pandemic in relationship to resuscitation practices. The first analytic step involved developing a templated summary table for each site that included key domains developed from the interview guide. Interviews were then reviewed and data corresponding to each domain was transferred into the table for further analysis. Findings from the completed summary table for each site were then compared across sites to identify convergent and divergent themes and patterns. This table, based on the interview guide, included key points from the interviews and exemplary quotes. Two team members (KMS and BKN) discussed emerging themes and reviewed data gleaned from the interviews over a series of three meetings. One meeting with all eight team members was then held to review data collected from the interviews, discuss patterns, and modify or expand upon emerging themes. Additional refinement through written correspondence with additional meetings was used for clarification. This study was approved by the institutional review board of the University of Michigan (HUM00095267).

Results
In total, 6 interviews with 10 key informants were conducted between November 2020 and April 2021, notably occurring over the course of two prominent COVID-19 surges. Table 2 lists characteristics of the hospitals. Hospital staff interviewed included physicians and nurses involved in care of IHCA patients, and yielded 5 hours and 44 minutes of interview time. Our analysis resulted in three main themes: 1) patient and provider safety and wellness; 2) protocols and training; 3) goals of care and end of life discussions. Technology related advancements and adaptations served as an underlying concept across the three main themes. These themes are described in detail below, along with exemplar quotes. Within each of the three main themes, we highlight issues related to technology advancements and adaptations. To preserve both site and staff anonymity, descriptors within quotes such as physical location, position, and names of staff were removed, while maintaining the integrity of the statement.

Patient and provider safety and wellness
Interviewees identified many changes made regarding safety and wellness among patients and health care workers (HCW) that were driven by the initial scarcity of information and resources during early surges. One prominent change involved the use of personal protective equipment (PPE). Initially, the primary focus of PPE was ensuring broad protection prior to entering resuscitation rooms, which included gowns, gloves, N95 masks, and eye protection. In response to COVID-19, many institutions began to locate more PPE carts in intensive care units as well as creating resuscitation bags for responding personnel to carry, which included broad coverage PPE."Putting your PPE on first is what's most important." (Director of Adult Critical Care and Nursing; Hospital E) "We are no help to our patients if we don't take a few seconds to take care of ourselves first." (Critical Care APN; Hospital F) In addition to physical safety, mental health among HCWs during the initial surges was a concern amongst many and was disclosed by interviewees, unprompted by interviewers. Provider wellness and safety as addressed with a two-prong method described by several interviewees, which included bringing attention to not only physical, but mental wellness for HCWs. In response, behavioral health services were offered to HCWs in varying degrees and capacities, with many interviewees stating that lack of accessible and timely offering of these resources was a regret of theirs during the early stages of the pandemic.
"Taking a mental toll on everybody. . .hard to describe. . .you come to work with the goal to save somebody and every effort you are making. . .and they die alone. . .overwhelming" (Nurse Coordinator; Hospital C). "You are coming to work every day and you are just seeing people die" (Nurse Coordinator; Hospital C)

Technology advancements and adaptations related to patient and provider safety and wellness
At all hospitals, the interviewees described how advancements in technology were being used to minimize HCW exposure risk or prompted the need for additional changes in work processes. This included the implementation of automated compression devices, changes to ventilation strategies, and alterations in resuscitation team structure. Many interviewees reported introducing automated compression devices to their institutions for the first time, while others commented on the number of these devices increasing exponentially. Ventilation strategies varied widely with reports of compressions being held until an airway was obtained at certain institutions. Several different devices were crafted to place over a patient's mouth during compressions to limit exposure; these ranged from masks to clear acrylic boxes to makeshift tents. All interviewed sites reported the creation of 'inside vs outside' resuscitation teams. Inside teams were created with the intent to minimize the number of individuals at bedside to essential individuals only. Outside teams were made up of additional support staff such as social workers, representatives from radiology and pharmacy, with additional physicians and nurses, all of whom remained outside of the resuscitation rooms.
Communication during codes involving isolation rooms became imperative with new configurations of code teams. Different modes of communication included walkie-talkies, baby monitors, and converting patient rooms to more glass-centered to enable writing with markers was reported.
"When I'm in a code room the noise from the negative airflow, plus the PAPRs [powered air purifying respirators], plus people screaming over their equipment to talk to one another, is very loud." (Member of Medical-Surgical Emergency Team; Hospital B)

Protocols and training
Training processes and initiatives were not immune to the pandemic and saw significant change. Mock code frequencies decreased at some institutions given concerns about social distancing, but also due to increases in patient care load and staff limitations. There was the introduction of COVID-19 based mock codes, which placed a heavy emphasis on the appropriate donning and doffing of PPE, rapid ventilation strategies, and implementing and troubleshooting automated compression devices. Advanced cardiac life support (ACLS) training also saw pronounced changes. Most interviewees reported a hybrid model approach to ACLS training with a new virtual or on-line component, which resulted in less hands-on clinical opportunities. Training class sizes were also limited to accommodate social distancing, which resulted in decreased opportunities for staff to remain compliant with training. In response "grace" periods were introduced to allow staff to remain complaint with ACLS training, while balancing increases in patient care with limited ACLS training opportunities.
"Units are so busy the last thing they want to do is be told how to run a code blue when they are running five a day" (Nurse Coordinator; Hospital C) "Suspended from reality" [regarding simulations with social distancing implemented]. (Director of Adult Critical Care and Nursing; Hospital E).
Roles during IHCAs were also assigned at the beginning of shifts at some institutions given increasing IHCA numbers. This resulted in less confusion at the beginning of IHCAs and had the potential to limit the number of individuals entering a room unnecessarily.
Additionally, interviewees stated that there was the creation of several new healthcare teams regarding resuscitation practices and the treatment of COVID-19 patients to standardize care for this patient population. These included Anesthesia COVID-19 Airway teams, chill teams, and proning teams. Anesthesia COVID-19 Airway teams were created given the increased need for rapid sequence intubations within this population and provide this intervention in a timely manner. Chill teams brought together neurology, cardiology, and pulmonary critical care colleagues to establish cooling protocols given the increased incidence of IHCA amongst COVID-19 positive patients.

Technology advancements and adaptations related to protocols and training
Given increased mortality seen in this population as well as increases in patient volume, technology related developments involving protocols and training included the creation of early warning systems, similar to the National Early Warning Score (NEWS), within electronic medical records (EMR). These systems utilized vital signs and lab value trends as indicators to rapid response-based rounding teams for further assessment and evaluation.

Goals of care and end of life discussions
At the beginning of the pandemic there was uncertainty surrounding the clinical trajectory of patients related to not only the disease process of this new virus, but also resuscitation outcomes in this patient population. This uncertainty led to modifications in approaches to goals of care conversations as well as post resuscitation care. Some institutions reported readdressing 'Resuscitation versus Do Not Resuscitate' conversations sooner with COVID-19 patients compared to the non-COVID-19 cohort. Many interviewees expressed concern regarding the ability to obtain appropriate resuscitation status during the pandemic. Their concerns stemmed from visitor policies and the lack of family members at bedside. "COVID has changed our ability to get appropriate code status" (Nurse Coordinator; Hospital C) With high patient census numbers, many hospitals implemented visitor policies to limit HCW exposure, with impactful downstream effects observed by hospital staff.
"Normally you know they [family members] come in and see the tubes and see the lines and they may not understand what that means. But the visual picture of what their loved one's status is plays a big impact on decision making on whether they should be full code or whether they should die in peace, and that piece is now missing. It is broken." (Nurse Coordinator; Hospital C) "Some people are holding on to a full code status longer. . .if families could just come in they would say 'Let's stop all this'" (Director of Adult Critical Care and Nursing; Hospital E)

Technology advancements and adaptations related to goals of care and end of life discussions
Communication between families, patients, and patient care teams required rethinking during early stages of the pandemic. To address evolving visitor policy changes institutions began to deploy different communication tactics for family members at home to engage with their loved ones in the hospital, as well as with patient care teams. A variety of streaming devices were used including tablets, cell phones, and video streaming applications. However, there were still concerns that the lack of in-person presence of family members was affecting patient care. Support staff, including case managers and social workers, were called upon more frequently in attempts to assist with the communication barriers that resulted from the pandemic between family members and patient care teams.
"Not allowing family to come in has created this barrier. . .they don't understand the gravity of it. Having someone explain it to you over an iPad I don't believe is providing the same impact as if they were at bedside" (Nurse Coordinator; Hospital C) Discussion A retrospective study demonstrated an 11 % increase in IHCAs during the COVID-19 pandemic, with mortality ranging from 88 to 100 % within COVID-19 positive patients experiencing an IHCA. 5 Given these findings we sought to identify core themes related to changes in resuscitation practices during the COVID-19 pandemic, specifically early on during its first initial surges. Our investigation identified three themes related to how U.S. hospitals shifted in their resuscitation practices: patient and provider safety, protocols and training, and goals of care and end of life discussions. Underlying all themes were advancements and adaptations in technology that helped institutions address challenges related to these themes.
Patient and provider safety came under significant scrutiny with changing AHA guidelines regarding PPE use. The American healthcare community has seen three guideline changes published from AHA over the course of the pandemic thus far, which have stemmed from new variants, level of transmissibility, and IHCA outcomes amongst COVID-19 patients. 8-10 In January of 2022 with increased transmissibility of new variants the AHA published their latest guidelines recommending that HCWs should don appropriate PPE prior to engaging in components of cardiac arrest, including chest compressions. 9 Changes to resuscitation efforts were also seen on an international level with the European Resuscitation Council (ERC) publishing guidelines in June of 2020 addressing advanced life support for adults with suspected or confirmed COVID-19 infections. These changes were similar to those published by the AHA and included donning PPE prior to performing aerosol-generating procedures such as chest compressions, restricting the number of staff at bedside during resuscitation efforts, and use of mechanical chest compressions devices for prolonged CPR. 11 The International Liaison Committee of Resuscitation (ILCOR) also published guidelines early during the COVID-19 pandemic that detailed using PPE for aerosol generating procedures during resuscitation, in addition to considering defibrillation before donning PPE in situations where the provider assesses the benefits may exceed the risks. 13 Limiting potential exposures to HCWs including aerosolizing procedures was a topic that saw dynamic change, not only across institutions, but over the course of the pandemic. The make-up of resuscitation teams and their roles were modified to address the above concerns. Other methods of limiting HCW exposures included the wider use of automated compression devices and adaptations to ventilation strategies. While HCW safety was a priority early on, a recurring concern amongst interviewees was the emotional burden of the COVID-19 pandemic on HCWs. There have been several studies that have analyzed the impact of the COVID-19 pandemic on healthcare professionals' mental health, which have also revealed an increased prevalence of anxiety and depressive symptoms. 14,15 When approaching resuscitation protocols and training initiatives during the COVID-19 pandemic institutions adapted a variety of strategies. ACLS training began to incorporate a virtual learning component given the need for social distancing. Some training programs began utilizing video conferencing capabilities with computerized manikins for optimized social distancing experiences, while others focused on sanitization and facility preparation to minimize potential exposures. 16,17 To accommodate social distancing and increased patient care demands many institutions extended accreditation timelines, as noted by many interviewees. The AHA adapted to the evolving training environment for ACLS and expanded card renewal dates by 120 days in July of 2020. 18 Mock resuscitation training was also adjusted to include COVID-19 specific problems, as well as techniques to support social distancing.
With the increasing number of IHCAs amongst COVID-19 patients, new warning systems within EMRs, similar to NEWS, were developed to identify unstable or decompensating patients prior to a code. Prior studies have shown systems of this nature can reduce the number of IHCA with a subsequent decrease in in-hospital mortality, but outcomes surrounding these systems have yet to be assessed during the COVID-19 era. 19 Specific teams were created to address resuscitation practices as well as post resuscitation care during the COVID-19 pandemic, these included dedicated anesthesia teams, cooling teams, and proning teams. Proning teams were developed, not for resuscitation specifically, but to assist in proning and unproning patients given increasing incidence of COVID-19 induced acute respiratory distress syndrome (ARDS) cases and proven benefit in this positioning strategy. 20 Post cardiac arrest protocols were also addressed during early stages in the pandemic to deliver high levels of care for specific and high resource treatments. For example, hospitals discussed how extracorporeal membrane oxygen (ECMO) was offered with varying degrees to COVID-19 patients following IHCA and successful return of spontaneous circulation. The Extracorporeal Life Support Organization published new guidelines in May 2021 with data to suggest similar survival rates in COVID-19 ARDS patients compared to non-COVID-19 ARDS patients meeting indications for V-V ECMO with the awareness that COVID-19 patients may require longer durations on this method of support. [21][22][23][24][25][26] There are several limitations of this qualitative study that should be considered in its interpretation. First, interviews occurred during different periods of surges and thus may not reflect comprehensive changes and adaptations made to resuscitation practices following new discoveries and developments related to the COVID-19 virus. Second, our team did not review specific protocols regarding resuscitation practices at institutions which would been a valuable tool for triangulating results with our interview results. Third, we did not perform a quantitative survey to complement our qualitative study. This may be valuable in future studies to understand how changes in protocols shifted nationally. Fourth, additional work may also focus on longitudinal studies that should help ascertain the long-lasting effects of the COVID-19 pandemic on resuscitation practice changes as well as determine if changes made during periods of hospital strain will remain in place. Finally, we were limited to key informants from only 6 institutions. Although we attempted to find diverse institutions, our findings will not be representative for all health care institutions. This work remains hypothesis generating and should be used to complement additional quantitative studies that reflect changes in resuscitation practices.
In summary, we found U.S. hospitals responded to the COVID-19 pandemic with important changes in their resuscitation practices for IHCA that focused on patient and provider safety changes, protocol and training changes, and goals of care and end of life decisions. As changes and information surrounding the COVID-19 pandemic continue to develop, resuscitation practices for IHCA patients will remain dynamic.

Sources of Funding
The original HEROIC study was supported by the National Institutes of Health (RO1HL123980). S.L. Krein is supported by a Veterans Affairs Health Services Research and Development Service research career scientist award (RCS 11-222).