Clinical Pathways - OVERVIEW

Team Leads

    • Amy Berger, MD, PhD (University of California, San Francisco School of Medicine)
    • Alan A. Kubey, MD, (Thomas Jefferson University Hospital and Mayo Clinic)
    • Andrew Auerbach, MD, MPH (University of California, San Francisco School of Medicine)

Authors

    • Sneha Daya, MD (University of California, San Francisco School of Medicine)
    • Kristen Kipps, MD (University of California, San Francisco School of Medicine)
    • Rashmi Manjunath, MD (University of California, San Francisco School of Medicine)
    • Katie E. Raffel, MD (Denver Health, University of Colorado School of Medicine)
    • Noa Simchoni, MD, PhD (University of California, San Francisco School of Medicine)
    • Zhenya Krapivinsky, MD (University of California, San Francisco School of Medicine)
    • Nick Kattan, MD (University of Florida College of Medicine)
    • Kirsten Nieto, MD (University of Texas Austin, Dell Medical School)
    • W. Michael Brode, MD (University of Texas at Austin Dell Medical School)
    • Ethan Kuperman, MD, MSc (University of Iowa Carver College of Medicine)

Topic Area

Hospitalists trying to provide the best care to patients with COVID-19 have faced tremendous uncertainty, a flood of variable quality, and sometimes contradictory evidence. Although some professional groups have issued guidelines, these guidelines have themselves been based on smaller bodies of lower quality evidence than typically expected, reducing their generalizability and leaving substantial room for clinical judgment. On top of this, surging patient volumes and strained resources have created their own set of challenges; for example, local limitations in access to testing, supplies of key medications, and hospital capacity may have caused health care providers to deviate from recommended care. Finally, many important aspects of clinical care are not included in guidelines and are governed instead by institutional policies and norms.

We conducted a survey to provide a snapshot of COVID-19-related clinical practices across a wide range of domains. The survey period was December 17, 2020, to February 8, 2021. We received responses from 52 of 83 (62%) invitees. Our data skews heavily toward academic medical centers (AMCs), with 94% of respondents describing their hospital as an AMC and only a small fraction as a community (14%) or safety net (14%) hospital. Average hospital medicine census ranged from 26-50 to >300 with a median of 151-200. Peak COVID-19 census also ranged from 26-50 to >300, with a median of 101-150, and 71% of hospitals reported total hospital medicine censuses somewhat or far greater than usual at the peak of their COVID-19 surge.

Professional Guidelines

The National Institutes of Health (NIH) has released clinical practice guidelines for the management of COVID-19.1 In addition, multiple national professional societies have issued recommendations for specific aspects of COVID-19 care; for example, the Infectious Diseases Society of America (IDSA) regarding infection prevention, diagnosis, and therapeutics, and American Society of Hematology (ASH) regarding anticoagulation.2,3 The specifics of these guidelines and their timing in relation to key studies and publications will be summarized by clinical practice domain below. In addition, there are multiple important aspects of clinical care, like admission/discharge criteria and laboratory monitoring, which are not covered by existing guidelines and where consensus across institutions may provide useful guidance.

Participating Sites

map-clinical-pathways

Baylor University Medical Center – Dallas, TX
Beth Israel Deaconess Medical Center – Boston, MA
Cedars-Sinai Medical Center – Los Angeles, CA
ChristianaCare Health System – Newark, DE
Denver Health – Denver, CO
Emory University – Atlanta, GA
Froedtert Hospital/Medical College of Wisconsin – Milwaukee, WI
Jefferson Health – Philadelphia, PA
Johns Hopkins Bayview Medical Center – Baltimore, MD
Massachusetts General Hospital – Boston, MA
Mayo Clinic – Rochester, MN
Maine Medical Center – Portland, ME
Miriam Hospital- Brown University – Providence, RI
Mount Sinai Health System – New York, NY
Oregon Health & Science University – Portland, OR
Our Lady of the Lake – Baton Rouge, LA
Rush – Chicago, IL
Rutgers Robert Wood Johnson Medical School – New Brunswick, NJ
San Francisco General Hospital – San Francisco, CA
Stanford University – Palo Alto, CA
The Ohio State Wexner Medical Center – Columbus, OH
Tulane SOM – New Orleans, LA
UC Los Angeles – Los Angeles CA
UC San Diego – San Diego, CA
UC San Francisco – San Francisco, CA
UIHC – Iowa City, IA

UNC – Chapel Hill, NC
University of Florida – Gainesville, FL
University of Michigan – Ann Arbor, MI
University Miami – Miami, FL
University Health Network – Toronto, Ontario, Canada
University of California Davis Medical Center – Sacramento, CA
University of Chicago – Chicago, IL
University of Iowa – Iowa City, IA
University of Kentucky Healthcare – Lexington, KY
University of Minnesota – Minneapolis, MN
University of Missouri-Columbia – Columbia, MO
University of Nebraska – Omaha, NE
University of Pennsylvania – Philadelphia, PA
University of Washington Medical Center – Seattle, WA
Harborview Medical Center – Seattle, WA
University of Wisconsin Hospital and Clinics – Madison, WI
UNM – Albuquerque, NM
UPMC – Pittsburgh, PA
UT Austin DMS / Dell Seton Medical Center – Austin, TX
Vanderbilt University Medical Center – Nashville, TN
VCU Health System – Richmond, VA
Wake Forest – Winston-Salem, NC
Washington University in St. Louis – St. Louis, MO
Weill Cornell – New York, NY

  1. COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. National Institutes of Health. Accessed March 15, 2021.
  2. Bhimraj A, Morgan RL, Shumaker AH, et al. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. Accessed March 15, 2021.
  3. Cuker A, Tseng EK, Nieuwlaat R, et al. American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19. Blood Adv. 2021;5(3):872-888. doi: 10.1182/bloodadvances.2020003763