Last March, as the COVID-19 pandemic reached Indiana, a team of infectious diseases physicians at Indiana University joined forces to develop a blueprint for treating patients with this novel disease. This blueprint, called the “COVID-19 treatment algorithm,” is a living, highly responsive document that evolves in real-time as we learn more about COVID-19 and how best to treat it.
Haley Pritchard, MD, who is Medical Director of Antimicrobial Stewardship for IU Health, describes the algorithm as a flow chart, or a decision-making tree.
“It helps you classify the severity of the patient’s disease, and determine which treatments that the patient might be eligible for based on available resources and ongoing clinical trials,” Pritchard said.
Physicians often use similar algorithms to make decisions about the treatment of other diseases. This time, however, the people managing the algorithm initially had almost no information about the disease—one that was quickly pushing ICUs to capacity and causing immense suffering.
“When this started, we didn’t know anything, and then as the pandemic progressed it felt like we knew less and less,” said Lindsey Reese, MD, whose clinical practice is centered at the Richard L. Roudebush VA Medical Center. “It was just trial and error, and most ended up failing.”
But amid the chaos, uncertainty, and stress of the pandemic, these physicians—all in leadership roles at downtown Indianapolis hospitals—have continuously worked together to develop, reevaluate, and improve the algorithm. It quickly became, and remains, a vital resource for physicians who treat patients with COVID-19 at area hospitals.
Nicolas Barros Baertl, MD; Haley Pritchard, MD; Lindsey Reese, MD; and Bree Weaver, MD
Developing the algorithm
“On March 6, 2020, Indiana registered its first case of COVID-19. It was clear at that time we needed to develop a task force to lead the treatment protocols,” said Nicolas Barros Baertl, MD, who practices at IU Health Methodist and University Hospitals.
With valuable input from partners in pediatric infectious diseases, clinical pharmacy, family medicine, pulmonary and critical care, and nursing, the team began meeting weekly to establish the algorithm, review new data, and make recommendations.
“At first, everyone was learning how to best identify and care for patients with this virus, and our job as the treatment team was to review emerging literature and data about treatments that might work,” said Bree Weaver, MD, who is Chief of Infectious Diseases at Eskenazi Hospital.
Over time, they added some treatments, removed others, and adjusted their recommendations. They included annotated references to support their guidelines, and provided educational material to hospital teams.
The result was a complex, nimble document that could be used across different facilities and health systems, all of which had different resources to draw upon.
“Hospitals have different supply chains, which means they may or may not have access to certain treatments,” Weaver explained. “Furthermore, some hospitals were sites for particular clinical trials, and others were not, which determined which patients were eligible for the treatments being tested.”
Reese faced additional complexities at the VA, where treatments unapproved by the FDA can only be administered as part of a study. To meet that standard, she served as Principal Investigator for studies of some of the treatments.
In addition to their work on the algorithm, these physicians also took on additional roles related to the mitigation of SARS-CoV-2 infection and the development of additional treatment recommendations. For example, Barros Baertl collaborated with the transplant team and the Indiana Donor Network to put protocols in place to decrease the risk of infection during organ transplants.
“These recommendations led to acceptance of multiple organ donations across the state,” he said.
Additionally, Pritchard established the COVID-19 Treatment Registry, which became an important complement to the algorithm. It tracked patient outcomes, as well as the treatments’ safety and efficacy data. (Pritchard presented the registry at Infectious Diseases Society of America’s ID Week virtual conference in October.)
“The registry alerted us to early signals about harm,” she said.
Unwitting harm was an unfortunate reality during the first half of the pandemic. Like their colleagues around the world, the team was eager to incorporate treatments into the algorithm that initially seemed promising, such as hydroxychloroquine, the HIV drug Kaletra, and convalescent plasma. But when new data emerged that these treatments were ineffective at best and harmful at worst, they had to be removed, leaving physicians with few options for their patients.
This was a very challenging, stressful time for Infectious Diseases physicians, who were then required to attend ICU rounds and consult on every COVID case.
“As infectious disease doctors in a pandemic, your colleagues are looking to you to lead them through it, and come to you with questions,” Reese said. “To constantly have to tell them that you don’t know, or to tell them something that later turns out to be misinformation—it was demoralizing.”
Despite these difficulties, Pritchard, Barros, Weaver and Reese all agreed that the unprecedented collaboration and camaraderie among the team members was incredibly motivating.
“Things are changing all the time, and that has been challenging for us, but it’s also made this team so valuable,” Weaver said. “There were so many people working toward this. We were all focused on doing the best for our patients at our particular place of practice, but we wanted everyone to do well.”
One year in
As infection rates slow down and vaccination rates rise, the team has settled into a new rhythm. Compared to earlier iterations, today’s COVID-19 treatment algorithm is relatively simple. It recommends three treatments—the steroid dexamethasone; an antiviral medication called remdesivir; and, in rare cases, an immunosuppressant called tocilizumab—all of which are straightforward, non-experimental, and familiar to the physicians who treat COVID patients. Infectious Diseases specialists are no longer required to consult on every case, and the treatment team meets just once a month to review new data and make any needed tweaks.
“We’re still very diligent in reviewing new literature and keeping up with new treatments that come out, so that hasn’t changed,” Weaver said. “But we are more comfortable with evaluating the literature about COVID, and with caring for COVID patients.”
They have also established a framework for collaboration across facilities and specialties that may have a lasting impact beyond the pandemic.
“Being part of the treatment team has taught me how to think on my feet, and it’s been a crash course in interdisciplinary collaboration,” Pritchard said, stressing the “essential” role played by infectious disease pharmacists.
“I hope to not to have to use these same pandemic-related skills again anytime soon, but now that we’ve done it, we’ll know where to start for next time!” she said.
