The challenge of disseminating best science during a pandemic

Doctors treating COVID-19 patients face the greatest medical challenge since HIV/AIDS. Remdesivir shortens hospital stays for some, but evidence that it prevents death is, like the drug itself, in short supply.

That leaves front-line clinicians scrambling to steadily improve the supportive care they provide seriously ill patients, whose ranks are growing rapidly. The U.S. case count now stands at 4 million—over a quarter of the world’s cases. The death toll is over 143,000 with the pandemic’s end nowhere in sight.

In the absence of highly effective therapies or a vaccine, clinicians must determine the best methods for treating patients after they present with COVID-19. How should they adjust treatment based on the disease’s progression or differentiate care based on each individual’s symptoms and underlying conditions?

Overworked and harried doctors and nurses also need best practices for protecting themselves. Over 800 healthcare workers have lost their lives to the disease in the last six months, according to a media tracker.

The good news is clinicians have already learned a lot. They’ve learned by reaching out to the physicians who mounted the barricades during the initial outbreaks. For instance, New York doctors contacted their counterparts in China, many of whom had been trained in the U.S. Physicians from Johns Hopkins called the officials who set up the Javits Center field hospital in New York to learn what they needed to do to set up Baltimore’s convention center facility. 

By talking to colleagues and reading case reports, they’ve learned that oxygen-starved patients do better when prone, that is, bedded on their stomachs rather than their backs. They’ve learned to test for inflammatory markers in the blood, which may not appear until nine to 12 days after initial symptoms. 

They’ve learned they must look for the abnormal blood clots that accompany severe cases. Rather than rushing to put patients on ventilators when their oxygen levels plunge, they’ve learned they can get comparable or better results with less invasive measures, which reserves machines for the most seriously ill. 

The medical literature is overflowing with studies about these and other strategies. There have been more than 34,000 research reports mentioning COVID-19 in the past seven months, including over 3,000 studies offering data from clinical trials or containing reviews and analyses of existing evidence.

Digesting and transmitting this exploding body of knowledge to front-line clinicians is a herculean task. The traditional methods move slowly under the best of circumstances and become almost irrelevant during a pandemic.

The expert panels who write clinical practice guidelines need months to gather evidence, evaluate its relevancy and synthesize recommendations. Their draft guidelines must undergo peer review before being published in journals and disseminated to practitioners. When you’re dealing with a novel virus, where new research is arriving daily, those recommendations become outdated before they even arrive.

Electronic support systems face a similar problem. Handheld devices rely on clinical practice guidelines to provide insight on symptoms and advice on treatments. Electronic health record systems that offer pop-up order sets must be reconfigured to reflect the latest evidence, which puts the onus on individual hospital systems to figure out what the best practices actually are at any given moment in time.

Professional societies have turned to new technologies to disseminate best practices: webinars, podcasts and social media. But, “it’s not the signal, it’s the noise,” says Dr. William Jaquis, president of the American College of Emergency Physicians.

“Everybody is talking about their study and their experience.”

Dr. Kedar Mate, CEO of the Institute for Healthcare Improvement, suggests in emergency situations, like now, “the best way to go probably is coordinated analysis and information dissemination from science-informed leadership.”

In other words, as in so many aspects of America’s response to COVID-19, a little national leadership wouldn’t hurt.

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