In the early days of the COVID-19 pandemic, a group of pulmonary and critical care physicians at the Brigham got together to begin drafting critical care protocols for taking care of patients with COVID-19. Among them was Edy Kim, MD PhD, an attending physician in the Division of Pulmonary and Critical Care Medicine. Within weeks, the protocols had grown beyond critical care to cover all aspects of COVID-19 care, with contributions from experts across more than 15 disciplines at the Brigham.

But to keep up with the growing knowledge and data about treatment, the team knew they would need a resource that was accessible, searchable and adaptable, and one that could be made more widely available. C. Lee Cohen MD, MBA, a pulmonary and critical care fellow with a background in global health, recognized the opportunity to not only create a resource useful for Brigham clinicians, but also for those beyond the hospital.

“At the Brigham, we’re fortunate to have teams of leading experts who can confer, but at small hospitals, they may have just one hospitalist who is trying to stay on top of the literature and do what’s best for patients — sometimes by reaching out to hospitals like ours for guidance,” said Cohen. “We felt we had a moral imperative to share what we were doing with a broader audience.”

To create a resource that would help clinicians at the Brigham and beyond stay abreast, Cohen, Kim and colleagues began an endeavor that would become COVIDprotocols.org, rapidly-updated and vetted COVID clinical guidelines. To date, the online, open access guidelines have been accessed by more than 500,000 people in more than 190 countries with more than 1.5 million pageviews.

Borne of Great Need

Mark Zhang, DO, MMSc, a palliative care physician, Brigham associate chief medical information officer,  and medical director of the Brigham’s Digital Innovation Hub (iHub), heard about COVID Protocols at the beginning of the pandemic’s first surge. He contributed to its palliative care section.

“I looked at it and thought, ‘This is an incredible resource,’” said Zhang. “It gave me exactly what I needed. How do we scale this up?”

The iHub, which serves as a center for digital health at the Brigham, was well-positioned to help. Zhang reached out to Cohen to offer the iHub’s support in scaling up the resource using the Brigham’s reference application platform. They assisted the team in getting COVID Protocols onto the official Brigham app store and solidified formal agreements with outside vendors who had offered their services.

Rather than the more typical PDF, COVID Protocols started as a searchable website powered by a collaborative writing application (Google docs). This unique structure allowed COVID Protocols to rapidly scale up from its humble beginnings to an expansive resource. Its initial 40 pages have grown to more than 800 pages, and its team of contributors now includes over 200 physicians, nurses, respiratory therapists, pharmacists and epidemiologists. And its content spans 30 different disciplines, including diagnostics, therapeutics, respiratory, infectious disease, cardiology, hematology, nephrology and others.

“To our knowledge, COVIDprotocols.org remains the most comprehensive online and searchable COVID-19 site in the world, with detailed, step-by-step clinical guidelines,” said Kim.

For the Brigham and Beyond

Two versions of the site exist: one that is specific to the Brigham and one that has been written with colleagues from Open Critical Care (based out of University of California San Francisco) and Partners In Health to be relevant to a wide variety of settings and resource limitations. The latter has also been translated into Spanish (this work is funded in part by the United States Agency for International Development). The globally relevant reference tool can be accessed online at covidprotocols.org (bwh.covidprotocols.org for the Brigham-specific version and https://covidprotocols.org/es/ for Spanish).

The development and use of COVID Protocols extend the Brigham’s tradition of clinical care led by physician-scientists. Many of the Brigham experts contributing to the resource have led clinical trials investigating COVID-19 therapies that have shaped current guidelines and treatment practices.

And just as scientists’ and clinicians’ understanding of COVID-19 evolves, the guidelines are also ever-changing. Cohen and Kim note that although the COVID-19 vaccines are highly effective, the need for clinical innovation continues, driving changes to treatment recommendations, such as new guidelines for using tocilizumab, a medication previously used for rheumatoid arthritis. The team has received questions about how their protocols can inform public policy, concerns such as school reopening, oxygen delivery, supply chain management, long-term acute care hospital management and management in circumstances with limited resources.

“Multiple governments and hospitals have reached out to ask to adapt our protocols to their local situations, and our protocols have been used all over the world,” said Kim. “Based on inbound emails, we suspect that most of our engaged users are clinicians at smaller institutions, particularly those that do not have the capacity to have their own taskforces.”

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