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Front Line Acute Care Surgeon Perspectives from the COVID-19 Epi Center with SIS · The SHEA Podcast

• 0:11
  SPEAKER_01: Welcome to the podcast series.
• 0:12
  SPEAKER_01: We're all in this together, COVID-19 Allies in Infection Prevention, part of the Society for Healthcare Epidemiology of America's Rapid Response Program.
• 0:21
  SPEAKER_01: I'm Michael Calderwood, Associate Chief Quality Officer at Dartmouth Hitchcock Medical Center, and I will serve as your SHA moderator and speaker.
• 0:29
  SPEAKER_01: I'm also happy to welcome Dr.
• 0:30
  SPEAKER_01: Phil Berry, Professor of Surgery at Will Cornell Medical College, and an attending surgeon at New York Presbyterian Will Cornell Medicine, who will serve as your Surgical Infection Society speaker for today's podcast.
• 0:43
  SPEAKER_01: Discussion on the podcast does not reflect Shay's or SIS perspectives, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:54
  SPEAKER_01: Today's episode will focus on collaborations and how we as a team can work together to address the most important questions surrounding the COVID-19 outbreak.
• 1:02
  SPEAKER_01: Dr.
• 1:03
  SPEAKER_01: Berry, I would like to discuss what your organization has had to do to address COVID-19.
• 1:08
  SPEAKER_01: And in preparing for today's podcast, we had an opportunity to speak about the significant impact on ICU bed capacity and the need to flex to alternative care environments.
• 1:17
  SPEAKER_01: And I was hoping you'd give us the opportunity to speak a little bit about that and the impact on both COVID and non-COVID care.
• 1:25
  SPEAKER_00: Thank you, Dr.
• 1:26
  SPEAKER_00: Calderwood, and good day, everyone.
• 1:28
  SPEAKER_00: Speaking to you from New York City, which has been called the epicenter of the pandemic, we still have intensive care unit patients who are infected with SARS-CoV-2, and so this is ongoing issues.
• 1:42
  SPEAKER_00: Before I answer the question, I'd like to point out that as an acute care surgeon, a trauma surgeon, I'm also a fellow of IDSA.
• 1:50
  SPEAKER_00: And so I think I can bring the perspective today, both of the intensive care unit and of the operating room, and hopefully that will inform the discussions.
• 2:02
  SPEAKER_00: We began planning in earnest in early March for what we knew was going to be a hard-hitting phenomenon.
• 2:10
  SPEAKER_00: What we didn't recognize at the outset was how many times our planning had to change, how much fluidity and improvisation was required.
• 2:20
  SPEAKER_00: Preparing for a disease that made people sick very quickly, but also was something from which it took a very, very long time to recover.
• 2:28
  SPEAKER_00: Probably the most dislocating things for us was the order from the governor of New York State that we had to double our ICU bed capacity in anticipation.
• 2:39
  SPEAKER_00: We have normally 112 adult ICU beds at the Wild Cornell Medical Center, and we more than doubled that to more than 250 beds by decommissioning our operating rooms and stopping elective surgery before that was ordered.
• 2:57
  SPEAKER_00: We were able to take care of 38 critically ill patients in operating room pods.
• 3:02
  SPEAKER_00: Our post-anesthesia care units were turned into temporary intensive care units, as were most of our step-down units.
• 3:10
  SPEAKER_00: The planning for this was very disruptive.
• 3:14
  SPEAKER_00: Some units that were required for patient care had to have their electrical supply upgraded, others had to have their ventilation systems upgraded.
• 3:24
  SPEAKER_00: There really wasn't an area in the hospital that wasn't impacted by the need to prepare for this.
• 3:30
  SPEAKER_00: Elective surgery went to zero.
• 3:33
  SPEAKER_00: We too saw the phenomenon of people with acute illnesses being unwilling to come to the hospital, and our usual complement of emergency general surgery for a period of time dropped down to almost zero.
• 3:46
  SPEAKER_00: Over an eight-week period at our institution, we did about 500 operations.
• 3:52
  SPEAKER_00: Normally that's about four days' work for us.
• 3:55
  SPEAKER_00: So our operative volumes decreased by about 90% in concert with having to wrap up for this pandemic.
• 4:03
  SPEAKER_01: One thing I did want to take a moment to talk about is the planning phase and then the reality.
• 4:08
  SPEAKER_01: And I think that New York and other cities, local to us New England, Boston, were hit very hard in the first wave.
• 4:17
  SPEAKER_01: And we're beginning to hear about other states that as they've gone through a period of reopening, maybe experiencing a second wave and beginning to run up against their own ICU capacity issues.
• 4:28
  SPEAKER_01: We've done a lot of similar planning in terms of what we'd be able to flex in terms of what extra ventilators we have on hand, what space we could convert into ICU andor general care space as needed.
• 4:40
  SPEAKER_01: I just would love to hear your perspective on lessons learned as folks may begin to go through this on their own outside of New York City.
• 4:50
  SPEAKER_00: Well, it's really interesting that you should pose that question.
• 4:53
  SPEAKER_00: From my background in trauma, we're constantly doing disaster planning and scenario planning.
• 5:00
  SPEAKER_00: And think about this quite a bit.
• 5:01
  SPEAKER_00: Some of my colleagues actually make this type of forward-looking a focus of their careers.
• 5:08
  SPEAKER_00: The one message I would have is however much we planned, however much we looked ahead, things changed so fast in ways we couldn't anticipate because honestly, in the early phases of the disease, we didn't really understand what we were up against in terms of clinical manifestations.
• 5:28
  SPEAKER_00: So I would say formal planning was only a framework.
• 5:31
  SPEAKER_00: And flexibility and innovation, modifying protocols on the fly, coming up with new protocols was really the order of the day, or perhaps I should say the order of several months.
• 5:44
  SPEAKER_01: And you've actually written about that.
• 5:46
  SPEAKER_01: You've been chronicling some of what's gone on on a blog on the Surgical Infection Society website.
• 5:52
  SPEAKER_01: And one of those blogs talked about the need to change existing protocols, create new ones as we learn more about this disease, but also work with individuals that had been reassigned from other clinical duties and make sure that everyone's on the same page, which is not an easy feat.
• 6:10
  SPEAKER_01: I was hoping you could tell us a little bit about what you have changed in your practice and what has driven those changes at your hospital.
• 6:17
  SPEAKER_00: Well, there are so many domains in which we could extend that discussion.
• 6:22
  SPEAKER_00: We've talked about the operating room, and even now, as we begin to emerge from all of that, we have new programs in place to pre-screen even elective surgical patients to make sure that those most in need of operative care, surgical care, are receiving it.
• 6:39
  SPEAKER_00: But back at the height of this, with the overwhelming number of patients and also the sheer number of people inexperienced with critical care who had to help pitch in to take care of these patients, we had to change fundamentally how we communicated and what we communicated.
• 6:58
  SPEAKER_00: So the changes were absolutely fundamental.
• 7:02
  SPEAKER_00: With respect to coming up with a way to staff more than 100 new temporary intensive care unit beds, my colleagues in nursing, with our complete support, developed a program for the rapid training of non-critical care nurses to be able to function in a critical care environment.
• 7:24
  SPEAKER_00: In a space of 10 days, we provided emergency training to more than 400 registered nurses who were then redeployed to critical care areas and worked in teams with critical care nurses of experience to make sure simply that we could cover the house.
• 7:42
  SPEAKER_00: My own team had to extend our deployment into our burn unit, which became a COVID unit, and also across the street to our ambulatory surgery facility, where we had to convert an ambulatory endoscopy recovery area into an intensive care unit.
• 8:01
  SPEAKER_00: Changing the operating rooms, changing the way we communicated, changing how we communicated, preparing hundreds of additional personnel to assist in the caring for these critically ill patients are but four of numerous examples, to your point.
• 8:19
  SPEAKER_01: No, thank you.
• 8:19
  SPEAKER_01: I think that's really important.
• 8:20
  SPEAKER_01: And it'll be important to really take stock of some of that training and how that could translate to other facilities.
• 8:27
  SPEAKER_01: And there will be time, hopefully, to write about some of this.
• 8:30
  SPEAKER_01: You're still in the midst of battling this disease, but I think all of us could learn from some of the experiences you've had.
• 8:37
  SPEAKER_01: You know, one of the other things I did want to take some time on was the issue around shortages.
• 8:42
  SPEAKER_01: And a lot's been written about PPE shortages, but you've also blogged about issues, uh shortages with critical ICU medications, blood supply, ECMO, renal replacement, and ventilators.
• 8:54
  SPEAKER_01: And we've begun to struggle with this even locally, where you have pockets where individual hospitals will run into shortages of critical equipment or supplies.
• 9:04
  SPEAKER_01: And the question is, do you transfer the equipment and supplies or do you transfer the patients?
• 9:09
  SPEAKER_01: And I would hope to hear a little bit about how hospitals around New York handled some of those shortages.
• 9:15
  SPEAKER_00: Well, we've already talked about personnel shortages simply because we had more ICU beds to cover than we ever had before.
• 9:24
  SPEAKER_00: But there's another part of the personnel shortage piece that I think everyone should realize, and that is that we had a number of our colleagues fall ill to COVID.
• 9:36
  SPEAKER_00: The respiratory therapists were hit particularly hard with illness, their ranks depleted at 1.50%, which in turn made it challenging for us to do everything that we might have wanted to do in terms of sophistication and nuance in mechanical ventilation.
• 9:54
  SPEAKER_00: Our dialysis nursing cadre was also very hard hit in terms of losing about 50% of their personnel acutely.
• 10:03
  SPEAKER_00: So that put the burden of renal replacement therapy on the critical care nurses who are trained to do it.
• 10:09
  SPEAKER_00: But certainly the temporary ICU nurses had only the rudiments.
• 10:14
  SPEAKER_00: Our emergency department personnel were hit hard.
• 10:17
  SPEAKER_00: We had fellows go out sick.
• 10:20
  SPEAKER_00: We had residents go out sick.
• 10:22
  SPEAKER_00: Our clinical pharmacy manager went out sick.
• 10:25
  SPEAKER_00: And a couple of our colleagues and formal colleagues actually succumbed.
• 10:29
  SPEAKER_00: So there was a very high price to pay in terms of personnel.
• 10:33
  SPEAKER_00: In terms of medication, the biggest problems that we had were with fentanyl and eventually hydromorphone as we depleted our supplies of fentanyl.
• 10:44
  SPEAKER_00: We ran out very quickly of cisatricurium and had to substitute rockuronium.
• 10:49
  SPEAKER_00: We also ran out very early on of parenthal benzodiazepines and switched to enterol.
• 10:57
  SPEAKER_00: Probably the single biggest shortage that we had that people didn't realize.
• 11:02
  SPEAKER_00: And as you alluded, I think everyone was aware of the shortages of PPE and ventilators, but the incidence of acute kidney injury in this disease was much higher than had been anticipated.
• 11:15
  SPEAKER_00: We had a real problem finding enough dialysis machines and enough dialysate solution.
• 11:20
  SPEAKER_00: In fact, at one point our pharmacy was actually making homebrew dialysis solutions.
• 11:26
  SPEAKER_00: So the shortages were pervasive.
• 11:28
  SPEAKER_00: They were across the board.
• 11:30
  SPEAKER_00: They included personnel, medication, and equipment.
• 11:35
  SPEAKER_00: They have largely abated for now, although we worry about PPE as we resume elective surgery.
• 11:43
  SPEAKER_00: And these shortages, which were rolling shortages and required us to be very flexible with our protocols, really impacted every aspect of taking care of these patients.
• 11:54
  SPEAKER_01: You know, you do mention the PPE, and so much has changed with the guidelines around PPE as we've learned more about the disease, and we've learned about, as you mentioned, the tragedy of healthcare workers who have fallen ill or tragically succumbed to this disease.
• 12:11
  SPEAKER_01: Could you discuss a little bit about what you learned in terms of PPE and changes you made to PPE to better protect your frontline staff?
• 12:20
  SPEAKER_00: Well, most of my colleagues in the front lines, my immediate colleagues are surgeons, so we had a high degree of comfort in being in PPE for a long period of time.
• 12:29
  SPEAKER_00: One of the things that was crucial for us was not the availability of PPE, but to making sure that people who weren't accustomed to wearing it all the time did become accustomed to it and particularly not only how to don it, but how to DOS it.
• 12:51
  SPEAKER_00: We learned very quickly that the removal of PPE after being in a COVID cloud, if you will, was actually one of the highest risk undertakings.
• 13:03
  SPEAKER_00: And so we undertook an institution-wide education program supported by video materials, demonstrations, et cetera, to make sure that PPE could be removed carefully.
• 13:16
  SPEAKER_00: And once we did that, the number of personnel who were out with post-exposure prophylaxis, not necessarily clinical illness, decreased dramatically.
• 13:26
  SPEAKER_00: So just because you're wearing it, don't forget that the single most dangerous phase may be the removing of it.
• 13:34
  SPEAKER_01: That's really important.
• 13:35
  SPEAKER_01: And actually having someone that's there to help observe that DOFI procedure.
• 13:40
  SPEAKER_00: Yes.
• 13:40
  SPEAKER_00: One of my colleagues with tongue only partly in cheek referred to those people as DOFISER.
• 13:50
  SPEAKER_01: That's great.
• 13:51
  SPEAKER_01: So, you know, the one thing I did want to make sure we did take some time for is this process of looking ahead.
• 13:58
  SPEAKER_01: And a lot has been talked about about how long we'll be in this pandemic, this crisis.
• 14:05
  SPEAKER_01: And people are really beginning to look out, 18, 24 months.
• 14:09
  SPEAKER_01: And we do need to begin to resume some non-COVID operations, and particularly all of the critical medical surgical care that have been postponed.
• 14:20
  SPEAKER_01: And I wanted to hear from you in the OR side, what has changed in terms of the care for the non-COVID patients?
• 14:28
  SPEAKER_01: What's changed in the OR environment?
• 14:31
  SPEAKER_01: What challenges that's presented, and any concerns that you have about how that may impact outcomes for patients and how we can mitigate some of that?
• 14:40
  SPEAKER_00: The changes are numerous, and we're still working through them, to be honest, because we're only beginning to ramp up doing elective surgery again.
• 14:49
  SPEAKER_00: We've only been approved to proceed for about a week, and so we're still getting our procedures in place.
• 14:55
  SPEAKER_00: One thing that is certain is that all prospective elective surgical patients are going to have to have a nasal swab being negative within 72 hours of their proposed date of surgery.
• 15:08
  SPEAKER_00: One thing that we have done is change the way we facilitate preoperative preparation for patients in that now they can visit any laboratory in any one of our network facilities.
• 15:21
  SPEAKER_00: So, for example, if someone lives closer to one of our facilities in Queens or Brooklyn, they can minimize the travel back and forth for testing.
• 15:31
  SPEAKER_00: Within the operating room environment, we are encouraging everyone to not let their guard down with the doffing of PPE.
• 15:38
  SPEAKER_00: We do not have the full surgical team in the operating room when patients undergo intubation, because that is generally widely believed to be an at-risk procedure in terms of aerosolization.
• 15:52
  SPEAKER_00: And the other thing that has been given great attention, we've had to go out and purchase the technology for every one of our operating rooms, is that particularly with laparoscopic surgery, we're making sure that we have suction aspiration systems attached to all of our ports, attached to the suction equipment so that the smoke, which is actually a mixture of vaporized tissue suspended in carbon dioxide during laparoscopy, is vented away from the surgical field and also out of the operating room into the negative pressure ventilation systems, which have been augmented in all of our operating rooms.
• 16:31
  SPEAKER_00: We're highly attuned to keeping the OR environment as safe as we possibly can for patients as well as providers.
• 16:40
  SPEAKER_01: So finally, I do think it's important to recognize that the pandemic has required a significant amount of collaboration across specialties, and you've spoken a lot about this today.
• 16:51
  SPEAKER_01: The goal really has been to maximize clinical outcomes for our patients while at the same time protecting both those in the community and specifically those in the healthcare setting and our colleagues and other healthcare workers.
• 17:04
  SPEAKER_01: So as we come to the conclusion of our podcast, I wanted to give you an opportunity to discuss what you think are the most critical areas that we need to continue to work on together in addressing this pandemic, and if there's some unmet needs, particularly that we can work on as Shea and SIS together.
• 17:21
  SPEAKER_00: There's a huge unknown, and that unknown is what will be the natural history of this disease as community safeguards with respect to gathering in crowds, social distancing, wearing masks will portend for the future dissemination and indeed survival of this virus as a potential pathogen.
• 17:47
  SPEAKER_00: In New York City, just over the last weekend, there were large crowds gathering outside to the hundreds or thousands of people with little regard for the safeguards that have been put in place over the last couple of months.
• 18:01
  SPEAKER_00: Whether or not we will have a surge of cases, we don't know.
• 18:05
  SPEAKER_00: As you alluded at the beginning of our conversation, there are hot spots popping up in parts of the country.
• 18:12
  SPEAKER_00: And so I think in general, it's fair to assume and conduct ourselves accordingly that this is not over.
• 18:20
  SPEAKER_00: Our primary concern at this point is reopening and getting back to normal insofar as possible while maintaining surveillance and safeguarding safety.
• 18:32
  SPEAKER_01: Well, thank you so much for sharing your experience.
• 18:34
  SPEAKER_01: I'd like to thank our speaker today, Dr.
• 18:37
  SPEAKER_01: Phil Barry, for joining us and sharing his perspectives and experiences in dealing with the COVID-19 pandemic in New York City and across the state of New York.
• 18:47
  SPEAKER_01: I'd like to offer a sincere thank you from SHAY and SIS to all healthcare personnel for all that you're doing to respond to COVID-19.
• 18:55
  SPEAKER_01: This podcast can be accessed through SHAY's online education center, Learning CE, under the Rapid Response Program.
• 19:02
  SPEAKER_01: You will also find additional resources such as the recorded webinars, Healthcare Facility Outbreak Preparedness, and the SHAY COVID-19 Town Halls, as well as the additional podcast series, COVID-19 Updates, What We Know Now, which is released every Thursday.
• 19:17
  SPEAKER_01: That concludes this episode of the COVID-19 Allies and Infection Prevention Podcast Series.
• 19:22
  SPEAKER_01: Thank you for tuning in.