On Wednesday, March 25, a physician who has been on the front lines of the COVID-19 healthcare crisis in China, presented important clinical care management findings from his and his colleagues’ experiences, during a webinar sponsored by the Hayward, California-based Potrero Medical, which describes itself on its website as “a Silicon Valley-based predictive health company developing the next generation of medical devices with smart sensors and artificial intelligence. Founded in the historical Potrero Hill neighborhood, we emerged out of Theranova, a medtech incubator focused on tackling the biggest challenges in healthcare,” the company’s website explains.
Zhiyong Peng, M.D., Ph.D., spoke live from Wuhan, China. Dr. Peng is chair and professor of critical care medicine at Zhongnan Hospital and vice-director of the Center of Clinical Trials at Wuhan University, in Wuhan. He was one of a team of 14 physicians who on February 7 published an article in the JAMA Network, entitled “Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China.” That article provided important insights into clinical and clinical management issues that Chinese physicians encountered in managing the first COVID-19 cases in Wuhan.
The article analyzed 138 cases of hospitalized patients. As the authors of the article noted, “The medical records of patients were analyzed by the research team of the Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University. Epidemiological, clinical, laboratory, and radiological characteristics and treatment and outcomes data were obtained with data collection forms from electronic medical records. The data were reviewed by a trained team of physicians. Information recorded included demographic data, medical history, exposure history, underlying comorbidities, symptoms, signs, laboratory findings, chest computed tomographic (CT) scans, and treatment measures (i.e., antiviral therapy, corticosteroid therapy, respiratory support, kidney replacement therapy). The date of disease onset was defined as the day when the symptom was noticed. Symptoms, signs, laboratory values, chest CT scan, and treatment measures during the hospital stay were collected. ARDS was defined according to the Berlin definition.”
The authors wrote that “This report, to our knowledge, is the largest case series to date of hospitalized patients with NCIP. As of February 3, 2020, of the 138 patients included in this study, 26 percent required ICU care, 34.1 percent were discharged, six died (4.3 percent), and 61.6 percent remain hospitalized. For those who were discharged (n = 47), the hospital stay was 10 days. The time from onset to dyspnea was 5.0 days, 7.0 days to hospital admission, and 8.0 days to ARDS (). Common symptoms at onset of illness were fever, dry cough, myalgia, fatigue, dyspnea, and anorexia. However, a significant proportion of patients presented initially with atypical symptoms, such as diarrhea and nausea. Major complications during hospitalization included ARDS, arrhythmia, and shock. Bilateral distribution of patchy shadows and ground glass opacity was a typical hallmark of CT scan for NCIP. Most critically ill patients were older and had more underlying conditions than patients not admitted to the ICU. Most patients required oxygen therapy and a minority of the patients needed invasive ventilation or even extracorporeal membrane oxygenation. The data in this study,” they wrote, “suggest rapid person-to-person transmission of 2019-nCoV may have occurred. The main reason is derived from the estimation of the basic reproductive number (R0) based on a previous study. R0 indicates how contagious an infectious disease is. As an infection spreads to new people, it reproduces itself; R0 indicates the average number of additional individuals that one affected case infects during the course of their illness and specifically applies to a population of people who were previously free of infection and have not been vaccinated. Based on the report, R0 from nCoV is 2.2, which estimated that, on average, each patient has been spreading infection to 2.2 other people. One reason for the rapid spread may be related to the atypical symptoms in the early stage in some patients infected with nCoV.” Per all that, the authors wrote, “This report, to our knowledge, is the largest case series to date of hospitalized patients with NCIP.”
Speaking of what has been learned in Wuhan, Dr. Peng said on Wednesday that one of the key lessons is that “You need to organize medical resources with the help of government and health authorities. Especially for the ICU people to rescue patients. More ICU beds are needed.”
Per that, he said, “Our approach was first to shut off COVID-19 medical care from other forms of medical care in the hospital. After you do that, you can use all the appropriate medical resources for COVID-19 patients. And you can focus on those patients. Also, you need full protective equipment, including protective shoes, face shields. Protect yourselves from airborne droplets. And how do put on and take off the PPE”—personal protective equipment. And, per the putting on and taking off of PPE, he emphasized that “Training for that is very important.” Another important element, he said, “Is to monitor the patients for potential relapse of infection or illness.”
With regard to clinicians and other staff members in the hospitals in Wuhan, Peng noted that “Forty percent of our patients were medical workers.” What’s more, he noted, “Most infected healthcare workers were not working in the ICU or the ED, were working elsewhere in the hospital. The typical patient interacted with many different medical professionals.” Extremely rigorous cleaning and housekeeping protocols have also been important, as has the optimization of admitting processes.
Meanwhile, he noted, patient presentation in terms of symptoms remains inconsistent, and clinicians are still having revelations about patients as they are treated. That said, most patients who have tested positive have presented with fever, fatigue, and dyspnea (shortness of breath). Typically, patients who turned out to be positive also exhibited what’s known as “ground glass opacity” on chest CT scans, meaning multiple patches across different sections of the lungs. Typically, confirmed diagnoses came from observations of symptoms, combined with lab test and chest CT results, he said.