Table 4.

Lessons Learned From Mortality Reviews of COVID-19 Cases and System Changes.

Lessons Learned	System Changes, Dates implemented
Proning critically ill patients requires experienced staff	Proning teams created at each hospital who cared for ICU patients outside of the medical ICU. April 2020
Central platform is vital to easily and consistently communicate evolving care practices to frontline clinicians	Clinical decision support order set for COVID-19 added to EPIC electronic health record for entire health system (easily modifiable as recommendations changed). AMC-1: Adult Emergency Department, March 9, 2020 AMC-1: Pediatric Emergency Department, March 13, 2020 Inpatient units, April 10, 2020 JHHS: July 2020
Redeploying providers to new assignments and transitioning care (non-COVID to COVID) requires instruction	Checklists for converting units to and from biomode End of March 2020–June 2020 JHHS May 2020 Ensure providers remain on the unit/floors they are most familiar with whenever possible. Late March 2020 (remains the philosophy)
Lessons learned
High mortality can appear to be a clinical care issue, but when drilling down stemmed from the patient population.
When responding to a new disease in a pandemic and learning pathology at the bedside, it is important to approach mortality reviews with humility.
Cardiopulmonary resuscitation outcomes were better than reported in the literature for patients with COVID-19 experiencing cardiac arrest.
Higher central line-associated bloodstream infection and other hospital-acquired infection rates are most likely due to being critically ill and proned for a prolonged period.
When creating new units (both COVID and non-COVID), limiting the number of admissions per unit/floor per day was important.

Abbreviations: AMC-1, academic medical center 1; JHHS, Johns Hopkins Health System.