Pandemics, including the COVID-19 pandemic, disrupt traditional health care operations by overwhelming system resource capacity. This article describes the development and rapid deployment of a virtual hospital program within a large health care system and their early caring for patients with COVID-19.

Rationale: Prone positioning is an appealing therapeutic strategy for nonintubated hypoxic patients with coronavirus disease (COVID-19), but its effectiveness remains to be established in randomized controlled trials. Objectives: To identify contextual factors relevant to the conduct of a definitive clinical trial evaluating a prone positioning strategy for nonintubated hypoxic patients with COVID-19. Methods: We conducted a cluster randomized pilot trial at a quaternary care teaching hospital. Five inpatient medical service teams were randomly allocated to two treatment arms: 1 ) usual care (UC), consisting of current, standard management of hypoxia and COVID-19; or 2 ) the Awake Prone Positioning Strategy (APPS) plus UC. Included patients had positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing or suspected COVID-19 pneumonia and oxygen saturation less than 93% or new oxygen requirement of 3 L per minute or greater and no contraindications to prone positioning. Oxygenation measures were collected within 48 hours of eligibility and included nadir oxygen saturation to fraction of inspired oxygen (S/F) ratio and time spent with S/F ratio less than 315. Concurrently, we conducted an embedded implementation evaluation using semistructured interviews with clinician and patient participants to determine contextual factors relevant to the successful conduct of a future clinical trial. The primary outcomes were drawn from an implementation science framework including acceptability, adoption, appropriateness, effectiveness, equity, feasibility, fidelity, and penetration. Results: Forty patients were included in the cluster randomized trial. Patients in the UC group ( n = 13) had a median nadir S/F ratio over the 48-hour study period of 216 (95% confidence interval [95% CI], 95–303) versus 253 (95% CI, 197–267) in the APPS group ( n = 27). Patients in the UC group spent 42 hours (95% CI, 13–47) of the 48-hour study period with an S/F ratio below 315 versus 20 hours (95% CI, 6–39) for patients in the APPS group. Mixed-methods analyses uncovered several barriers relevant to the conduct of a successful definitive randomized controlled trial, including low adherence to prone positioning, large differences between physician-recommended and patient-tolerated prone durations, and diffusion of prone positioning into usual care. Conclusions: A definitive trial evaluating the effect of prone positioning in nonintubated patients with COVID-19 is warranted, but several barriers must be addressed to ensure that the results of such a trial are informative and readily translated into practice.

Family engagement is a key component of high-quality critical care, with known benefits for patients, care teams, and family members themselves. The COVID-19 pandemic led to rapid enactment of prohibitions or restrictions that now persist, particularly for patients with COVID-19. Reevaluation of these policies in response to advances in knowledge and resources since the early pandemic is critical because COVID-19 will continue to be a public health threat for months to years and future pandemics are likely. This paper reviews rationales and evidence for restricting or permitting family members’ physical presence and provides broad guidance for healthcare systems to develop and implement policies that maximize benefit and minimize risk of family visitation during COVID-19 and future similar public health crises.

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The implementation of EMR was associated with a decrease in face-to-face communication between physicians and nurses, and worsened overall agreement about the plan of care.