Latest / The SHEA Podcast / Critical Care Collaboration with SCCM

Transcript

Critical Care Collaboration with SCCM · The SHEA Podcast

• 0:11
  SPEAKER_00: Hello everyone and welcome to the We're All in This Together COVID-19 Allies in Infection Prevention Podcast Series as part of the Society for Healthcare Epidemiology of America SHA Rapid Response Program.
• 0:24
  SPEAKER_00: I am Dr.
• 0:25
  SPEAKER_00: Maira Al-Mohajer, Associate Professor at Baylor College of Medicine, and I will serve as your SHA moderator and speaker.
• 0:32
  SPEAKER_00: I'm also very happy to welcome Dr.
• 0:34
  SPEAKER_00: Louis Kaplan, the Society of Critical Care Medicine, SCCM's president and professor of surgery at the Pearlman School of Medicine at the University of Pennsylvania, who will serve as your SCCM speaker for today's podcast.
• 0:48
  SPEAKER_00: Discussion on the podcast does not reflect Shay's or SCCM's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 1:00
  SPEAKER_00: For today's episodes, we're going to focus on collaboration between healthcare epidemiology and the critical care and how we as a team can work together to address the most important questions surrounding this COVID outbreak.
• 1:14
  SPEAKER_00: Let's get started with our first question.
• 1:16
  SPEAKER_00: So, Dr.
• 1:17
  SPEAKER_00: Kaplan, could you please describe you or your organizations what you're doing in order to address COVID-19?
• 1:25
  SPEAKER_01: Sure, it is certainly a pleasure to be here.
• 1:27
  SPEAKER_01: Let me address this first question by putting what we're doing into a couple of different units.
• 1:33
  SPEAKER_01: The first thing is that we relied on our strength.
• 1:37
  SPEAKER_01: We are in large part an education society.
• 1:39
  SPEAKER_01: You may have noticed that much of what would previously exist behind a paywall, our fundamental critical care support, fundamental disaster management, has been taken out from behind that paywall and made free in a very free open access medical education format.
• 1:57
  SPEAKER_01: And it was really important that we did that because it took some of the key elements that would help prepare non-ICU clinicians to work in the ICU to get up to speed.
• 2:08
  SPEAKER_01: And we'll come back to that in a little bit.
• 2:11
  SPEAKER_01: Concominant with that, we redesigned our website.
• 2:14
  SPEAKER_01: We're no different than many other medical professional organizations in that there are COVID-19 resources that have been curated, partly from within what we already had, but also links to other places and other sites that had important information for members, but also non-members.
• 2:34
  SPEAKER_01: So we had a very public-facing aspect of the website around pandemic resources.
• 2:40
  SPEAKER_01: At the same time, we took our journals, Critical Care Medicine, Pediatric Critical Care Medicine, and our open access journal, Critical Care Explorations, and identified all of the COVID-related resources within them.
• 2:55
  SPEAKER_01: So we took the usual aspects of navigation, the typical aspects of education, and redirected them so that there were resources that people could leverage and rely upon to help address clinical care in their setting.
• 3:11
  SPEAKER_01: But that doesn't really relate to healthcare epidemiology.
• 3:14
  SPEAKER_01: The last thing is that we did really does.
• 3:17
  SPEAKER_01: We set up a very robust and global database called Virus.
• 3:22
  SPEAKER_01: And Virus allowed people in sites around the world to take what they are doing with patients, patient information, kinds of clinical care, outcomes, and put it all in one space using a single platform.
• 3:38
  SPEAKER_01: At this point, they have about 15,000 very granular patients that are loaded into that database, and that does help with healthcare epidemiology.
• 3:47
  SPEAKER_01: The other piece that we also did was that we established a guideline with the Surviving Sepsis campaign, which, as you recall, is really a partnership between the European Society of Intensive Care Medicine and the Society of Critical Care Medicine.
• 4:03
  SPEAKER_01: Knowing that people would need guidance and that people would then share with us what they did with that guidance, we opened a portal for member insights, member educational resources that they developed and to share stories around how they cared for patients.
• 4:20
  SPEAKER_01: And this dovetailed with what we did on social media, Facebook, and principally Twitter.
• 4:26
  SPEAKER_01: You've probably noticed that the president's Twitter feed has been filled with COVID kinds of things at the same time that perhaps you like something that wasn't exactly COVID all in the same space.
• 4:37
  SPEAKER_00: Sounds very interesting.
• 4:38
  SPEAKER_00: I really um like that you mentioned related to focus on education.
• 4:43
  SPEAKER_00: I think it's particularly important, especially as we see a need for more people covering the ICU.
• 4:50
  SPEAKER_00: So I've seen it at many hospitals that's uh asking uh other people to help and join.
• 4:54
  SPEAKER_00: So really thank you for your leadership on this.
• 4:57
  SPEAKER_00: I want to ask you related to um like challenges.
• 5:01
  SPEAKER_00: So uh you mentioned you have several projects going on.
• 5:04
  SPEAKER_00: What would be the biggest challenge that you had related to COVID and how have you handled it to date and how has that worked?
• 5:13
  SPEAKER_01: The question is superb because the biggest challenge, if your hospital is like mine, was the opening of novel ICUs.
• 5:22
  SPEAKER_01: Places that were previously destined for acute care, but now needed to function as if they were an ICU space.
• 5:30
  SPEAKER_01: You've probably read about or seen places that were conference centers or exam rooms or ORs or post-anesthesia carinet rooms.
• 5:39
  SPEAKER_01: The ability to stand those up and make them critical care capable was only half of that equation.
• 5:46
  SPEAKER_01: We developed some resources to help guide how you would adjust those rooms, how you make them safe for critical care patients.
• 5:53
  SPEAKER_01: But you must staff them.
• 5:55
  SPEAKER_01: And not only staff them, but you also must have patient allocation and administration of the people working in those spaces.
• 6:02
  SPEAKER_01: That really was the biggest challenge, finding individuals to staff those spaces.
• 6:07
  SPEAKER_01: Those free open access educational resources, those have been downloaded about 600,000 different times.
• 6:15
  SPEAKER_01: And I can tell you that people like me, I'm not unique in this, there are many FCCS and FDM instructors all around the world.
• 6:24
  SPEAKER_01: They've taken those resources and then trained even more than that 600,000 to work in the ICU in a tiered staffing model where they're working alongside of seasoned clinicians, even if it wasn't really their space.
• 6:40
  SPEAKER_01: We've trained ophthalmologists and rheumatology fellows and orthopedic surgeons, which orthopedic surgeons in the ICU sounds a little bit odd, but you know, they excelled at things that you didn't expect.
• 6:53
  SPEAKER_01: All of the people that were prone, well, orthopedics prone people all the time for access.
• 6:58
  SPEAKER_01: They they were superb.
• 7:00
  SPEAKER_01: And so that around this challenge and the education, it has worked incredibly well discovering new uses for existing skills, all in the quest for clinical care excellence.
• 7:14
  SPEAKER_00: That's very interesting, and I'm really glad you were able to overcome these challenges.
• 7:19
  SPEAKER_00: I can say that's definitely the importance of critical care right now and the need for uh people to start the ICU.
• 7:26
  SPEAKER_00: So really appreciate all the work that you're doing because I think that's really critical to face the pandemic.
• 7:33
  SPEAKER_00: So I'm sure you have done uh many changes to the practice of critical care with COVID.
• 7:39
  SPEAKER_00: Can you tell us a little bit about what factors that have driven those changes and describe a little bit those changes and the challenges that they have presented?
• 7:49
  SPEAKER_01: Sure.
• 7:50
  SPEAKER_01: These really have related to the epidemiology and spread of virus, while we protect patients from spread, but also healthcare clinicians from contracting SARS-CoV-2 infection.
• 8:03
  SPEAKER_01: We have leveraged a lot of care by moving it outside of the room, moving pumps outside of the room, taking, let's say, ventilator control panels and moving them outside of the room, limiting the number of times the people do and don't go in, changing the kinds of medications that we use to some that are perhaps more long-acting, especially during shortages.
• 8:27
  SPEAKER_01: But all the while, it has impacted medical education and trainee education.
• 8:34
  SPEAKER_01: If you think about what's happened in many places with PPE on shortage, the medical students are no longer in that space.
• 8:42
  SPEAKER_01: For many trainees and fellowships, there are limits for how many rotations and months they can have in the ICU.
• 8:50
  SPEAKER_01: So we've learned how to rotate people in and out to respect those boundaries.
• 8:55
  SPEAKER_01: We have taken consultants and reduced their bedside time or the need for bedside time by having consultation outside of that bedside space.
• 9:05
  SPEAKER_01: But the biggest thing that has happened is that we moved patients' families out of the hospital.
• 9:13
  SPEAKER_01: We restricted visitation and in many ways virtually eliminated it.
• 9:19
  SPEAKER_01: The communication to support family-centered care and shared decision making took novel approaches.
• 9:26
  SPEAKER_01: Many of us are now very conversant with a Zoom meeting, but we weren't perhaps six or twelve months ago.
• 9:33
  SPEAKER_01: Families are now conversant with that.
• 9:36
  SPEAKER_01: And unlike what happens in the hospital where everyone is hidden behind a hat and goggles and a mask and PPE, during that video meeting with family that can't be there at the bedside, well, you can take that off and you can use social cueing that we're so used to relying on with microexpressions on people's faces just to understand exactly what they mean, even if they can't be there in person.
• 10:03
  SPEAKER_01: So that has significantly shifted the landscape of how we communicate with families, how we share good news as well as bad news, and make decisions for patients who are incapable of making those decisions for themselves.
• 10:17
  SPEAKER_01: It is a unique skill set that the families had to develop, and we have now certainly refined and expand as we increase the ability to use telehealth and telecritical care.
• 10:29
  SPEAKER_01: So those are vast changes that have been made to practice all around the epidemiologic implications of having people in the same space with a contagious virus.
• 10:41
  SPEAKER_00: You mentioned that you try to maybe work with the consultants on a way to limit transmission in the units by having a different model of consultation.
• 10:50
  SPEAKER_00: Can you a little bit elaborate that?
• 10:52
  SPEAKER_00: I think that would be important to hear, especially many of our listeners are ID consultants themselves.
• 10:59
  SPEAKER_00: Sure.
• 11:00
  SPEAKER_01: Much of the information is already contained in the electronic health record, but there are elements of care that really benefit from being able to see it.
• 11:09
  SPEAKER_01: And so that putting an iPad or a dedicated phone in that room so that when a consultant needs to see what something looks like or how a patient responds to a particular provocative test, we can share that by video, which is very different than them having to come and do it themselves and see it.
• 11:27
  SPEAKER_01: So they can witness these things at a remove.
• 11:31
  SPEAKER_01: Therefore, they don't use PPE that is precious because they don't have to gown up and go in, they don't expose themselves, they don't break the door barrier if you don't have a negative pressure room, maybe you have neutral pressure.
• 11:44
  SPEAKER_01: And it allows for very close collaboration between the bedside ICU clinician and the consultant.
• 11:52
  SPEAKER_01: And what we've found works so well is that when the person who's not an ICU clinician that's working in the ICU is in the same discipline as the consultant, they know exactly what the other person needs to see and needs to hear and needs to witness.
• 12:09
  SPEAKER_01: So that has allowed a lot of our consultation to occur at a remove, even supported by bedside critical care echocardiography for routine evaluations more or less of LV function or volume status.
• 12:24
  SPEAKER_01: Structural things, that's that's not what we do.
• 12:26
  SPEAKER_01: We really do need the cardiology consultant to see that image and have it obtained in a very precise fashion.
• 12:32
  SPEAKER_01: But the rest of it, it works incredibly well, leveraging telehealth even within the same institution as opposed to without it.
• 12:43
  SPEAKER_00: You've done a lot with this, and I really like all that you've done.
• 12:47
  SPEAKER_00: And it seems it's really helpful to minimize the people going into the ICU so it can limit the transmission.
• 12:55
  SPEAKER_00: I want to ask you like maybe some hot topic related to WHO mentioned a little bit about that.
• 13:10
  SPEAKER_01: A lot of hospitals have made a few important changes.
• 13:14
  SPEAKER_01: And truly, South Korea did this very well.
• 13:16
  SPEAKER_01: Their ICU beds are principally negative pressure rooms.
• 13:20
  SPEAKER_01: Not all of US ICU beds are negative pressure rooms.
• 13:24
  SPEAKER_01: So that the installation of HEPA filtered air exchangers or air handlers and the ability to create negative pressure, even with a somewhat noisy device that sits through a hole that's cutting into the window, has been a major change.
• 13:41
  SPEAKER_01: It has definitely guided how you create negative pressure across spaces using existing air handling machines.
• 13:50
  SPEAKER_01: If you would like air conditioning at the same time, it is a vast burden on your devices if you make everything negative pressure.
• 13:57
  SPEAKER_01: So facilities have had significant expenditures in terms of structural support, all at the same time that they've had decreased elective procedures that certainly impact their cash flow, but they have stood up for critical care.
• 14:13
  SPEAKER_01: Remember, this is the time frame when intensivist was finally defined by Merriam-Webster.
• 14:18
  SPEAKER_01: And hospitals have bought into that and they've supported our need for aerosol-based modifications of the existing rooms, and they've supported all kinds of changes to PPE, routine goggles, uh much more widespread N95 use, reprocessing of N95.
• 14:37
  SPEAKER_01: We would never have done that before, but we've experimented for how to make that work, all in the name of safety, because this is fundamentally different from what we have done before.
• 14:50
  SPEAKER_01: You may have worried about coming into contact with MERSA or multidrug resistant organism, but soap and water was just fine.
• 14:58
  SPEAKER_01: Now the donning and doffing that is occasionally difficult to do just perfectly at the end of 12 hours, or if you do trauma, maybe it's the end of 30 hours, is very challenging and very stressful.
• 15:11
  SPEAKER_01: So the support that facilities have embraced to help with those changes in critical care practice has been immeasurable.
• 15:21
  SPEAKER_00: You really described some really big changes that we have witnessed recently.
• 15:25
  SPEAKER_00: And as you said, prior to the pandemic, we would not be using N95 more than once, and now definitely we have changed our practice based on the shortages.
• 15:37
  SPEAKER_00: Final question for you is what opportunities do you think are there for individuals working in healthcare, EPI, and critical care for during this pandemic?
• 15:46
  SPEAKER_00: And two, like long-term.
• 15:48
  SPEAKER_01: Sure, I think that this falls into two discrete areas.
• 15:52
  SPEAKER_01: One is that the hospital principally functions like its own space, and there is an opportunity to embrace pre-hospital care, be it very standard emergency medical services, or if you're like we are at Penn, we have significant police drop-off of injured individuals, principally those that have suffered firearm violence, but they are engaged in that initial frontline care.
• 16:17
  SPEAKER_01: And we need to perhaps incorporate them as Maurizio Cecconi, the president-elect for the European Society of Intensive Care Medicine, has advocated for as really a healthcare army.
• 16:28
  SPEAKER_01: Everyone that has an integrated role.
• 16:30
  SPEAKER_01: That's one piece.
• 16:32
  SPEAKER_01: The other is that you've probably seen this.
• 16:35
  SPEAKER_01: You've seen the people that worked really incredibly hard during the upstroke of COVID-19.
• 16:43
  SPEAKER_01: And they were really looking forward to having a little bit of respite.
• 16:47
  SPEAKER_01: And at the same time that they're looking forward to that, as their COVID numbers began to go down, hospitals began to ramp up their normal operations.
• 16:56
  SPEAKER_01: Therefore, there really wasn't a break, and we are at risk of taking seasoned, experienced individuals who have viewed critical care as their really their life's work instead of just a job.
• 17:10
  SPEAKER_01: And we're at risk of having them decide that this is not the pace at which they can sustain working.
• 17:17
  SPEAKER_01: It doesn't matter whether you're talking about physicians or advanced practice providers or bedside nurses or respiratory therapists, they were really hit hard.
• 17:25
  SPEAKER_01: They are at risk.
• 17:27
  SPEAKER_01: They are a population that we should not fail to identify within the epidemiology of the consequences of pandemic care.
• 17:35
  SPEAKER_01: And we should make sure that we rescue them.
• 17:38
  SPEAKER_01: We should make sure that we can help them to be resilient.
• 17:42
  SPEAKER_01: It will be more than just food or beverages.
• 17:45
  SPEAKER_01: It really is a structural approach to enhancing viability in the long term of people that are on the front lines with a very different risk set and work burden than what we have had in the past.
• 17:58
  SPEAKER_01: So those are two very key things that I think we can do together to help face the future.
• 18:05
  SPEAKER_00: Well, I cannot agree with you more.
• 18:07
  SPEAKER_00: With this reach to closing, so thank you very much to our speaker, Dr.
• 18:12
  SPEAKER_00: Kaplan, for joining us today and sharing your perspective and experiences.
• 18:16
  SPEAKER_00: And a sincere thank you from Shay and to all healthcare personnel for all what you've been doing to respond to COVID-19.
• 18:24
  SPEAKER_00: This podcast can be accessed on Shay's online education center, learning CE under the Rapid Response Program.
• 18:30
  SPEAKER_00: You will also find additional resources such as recorded webinars, healthcare facility output preparedness, and SHA COVID-19 downhauls and the additional podcast series COVID-19 update, what we know now, which is released every Thursday.
• 18:46
  SPEAKER_00: That concludes our episodes of the Allies and Infection Prevention Podcast Series.
• 18:50
  SPEAKER_00: Thank you very much for tuning in.