Protocol Failure Detection: The Conflation of Acute Respiratory Distress Syndrome, SARS-CoV-2 Pneumonia and Respiratory Dysfunction

Lawrence A Lynn; Emily Wheeler; Russel Woda; Alexander B Levitov; Stanislaw P Stawicki; David P Bahner

doi:10.4103/jets.jets_75_21

Protocol Failure Detection: The Conflation of Acute Respiratory Distress Syndrome, SARS-CoV-2 Pneumonia and Respiratory Dysfunction

J Emerg Trauma Shock. 2021 Oct-Dec;14(4):227-231. doi: 10.4103/jets.jets_75_21. Epub 2021 Dec 24.

Authors

Lawrence A Lynn¹, Emily Wheeler², Russel Woda³, Alexander B Levitov⁴, Stanislaw P Stawicki⁵, David P Bahner⁶

Affiliations

¹ Department of Pulmonology, OhioHealth Doctors Hospital, Columbus, Ohio, USA.
² Department of Emergency Medicine, Florida State University, Sarasota Memorial Hospital, Sarasota, Florida, USA.
³ Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA.
⁴ Department of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, Virginia.
⁵ Department of Research and Innovation, St Luke's University Health Network, Bethlehem, Pennsylvania, USA.
⁶ Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA.

Abstract

In medicine, protocols are applied to assure the provision of the treatment with the greatest probability of success. However, the development of protocols is based on the determination of the best intervention for the group. If the group is heterogeneous, there will always be a subset of patients for which the protocol will fail. Furthermore, over time, heterogeneity of the group may not be stable, so the percentage of patients for which a given protocol may fail may change depending on the dynamic patient mix in the group. This was thrown into stark focus during the severe acute respiratory syndrome-2 coronavirus (SARS-CoV-2) pandemic. When a COVID-19 patient presented meeting SIRS or the Berlin Criteria, these patients met the criteria for entry into the sepsis protocol and/or acute respiratory distress syndrome (ARDS) protocol, respectively and were treated accordingly. This was perceived to be the correct response because these patients met the criteria for the "group" definitions of sepsis and/or ARDS. However, the application of these protocols to patients with SARS-CoV-2 infection had never been studied. Initially, poor outcomes were blamed on protocol noncompliance or some unknown patient factor. This initial perception is not surprising as these protocols are standards and were perceived as comprising the best possible evidence-based care. While the academic response to the pandemic was robust, recognition that existing protocols were failing might have been detected sooner if protocol failure detection had been integrated with the protocols themselves. In this review, we propose that, while protocols are necessary to ensure that minimum standards of care are met, protocols need an additional feature, integrated protocol failure detection, which provides an output responsive to protocol failure in real time so other treatment options can be considered and research efforts rapidly focused.

Keywords: Acute respiratory distress syndrome; COVID-19; SARS-CoV-2; protocol failure.

Publication types

Review