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Anesthesiology During a Pandemic with ASA · The SHEA Podcast

• 0:07
  SPEAKER_01: Welcome to the podcast series.
• 0:09
  SPEAKER_01: We're all in this together: COVID-19 Allies in Infection Prevention.
• 0:13
  SPEAKER_01: As part of the Society for Healthcare Epidemiology of America, SHA's Rapid Response Program.
• 0:18
  SPEAKER_01: I'm Dr.
• 0:19
  SPEAKER_01: Marcy Drees, Chief Infection Prevention Officer and Hospital Epidemiologist at Christiana Care, and I'll be serving as your SHA moderator and speaker for today's podcast.
• 0:28
  SPEAKER_01: I'm also happy to welcome Dr.
• 0:29
  SPEAKER_01: Grant Lindy, Vice Chair of Quality Improvement, Department of Anesthesiology at Emory University School of Medicine, who will serve as your American Society of Anesthesiologists, ASA speaker for today's podcast.
• 0:42
  SPEAKER_01: Discussion on the podcast does not reflect Shay's or ASA's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:52
  SPEAKER_01: Today's episode will focus on collaborations between healthcare epidemiology and anesthesiology and how we can, as a team, work together to address the most important questions surrounding the COVID-19 outbreak.
• 1:03
  SPEAKER_01: Thank you, Dr.
• 1:03
  SPEAKER_01: Lindy, for being here.
• 1:04
  SPEAKER_01: Let's get started with our first question.
• 1:06
  SPEAKER_00: Great, thank you.
• 1:08
  SPEAKER_01: Could you please describe what ASA has been doing to address COVID-19?
• 1:12
  SPEAKER_00: I think COVID-19 has done three things with us as an organization.
• 1:17
  SPEAKER_00: And it has focused us on providing member education on how to respond to COVID-19 and provide more information around COVID-19 through a series of town halls.
• 1:29
  SPEAKER_00: I think one thing that a lot of individuals don't really think about until they actually sit down and talk about is anesthesiology touches so many areas in the hospital from intoperative management, critical care, as well as rapid response orientation.
• 1:44
  SPEAKER_00: So greeting everybody that type of education and helping them focus on it has helped.
• 1:49
  SPEAKER_00: And these sessions attend as close to 5,000 anesthesiologists and semesters on these topics that also allow for some QA.
• 1:58
  SPEAKER_00: It's also made us confront ideas related to policy and direction of our members through a series of how-tos.
• 2:07
  SPEAKER_00: So we've really reached out to our membership and provide additional answers where governmental agencies haven't really had sufficient answers for us.
• 2:16
  SPEAKER_00: So, for example, PVE during intubations would be one great example of where we as an organization had to step in and fill an informational void that has existed on a federal level.
• 2:29
  SPEAKER_00: And then the third aspect is federal advocacy.
• 2:33
  SPEAKER_00: So as hopefully everybody's aware, the federal government has done a lot to suspend and withdraw a lot of their regulation oversight to provide hospital systems the flexibility to respond and take care of what their local needs are.
• 2:49
  SPEAKER_00: However, we as an organization need to ensure that the standards for patient safety aren't ignored during crisis mode.
• 2:56
  SPEAKER_00: A good example of that also is medication shortages.
• 3:00
  SPEAKER_00: And as everybody's aware, there were initially acute shortages of fentanyl, neurovascular blocking agents.
• 3:08
  SPEAKER_00: And as an organization, we've had to advocate for our members to ensure continuing supply for critical patient care needs.
• 3:17
  SPEAKER_01: Great, thank you.
• 3:18
  SPEAKER_01: What do you feel anesthesia's biggest challenge has been around COVID-19 and how have you handled it to date?
• 3:24
  SPEAKER_00: I think that the biggest challenges for us as a specialty has been, number one, the issues related to PPE and provider safety.
• 3:34
  SPEAKER_00: And from prior crises, we've known that intubation is one of the riskiest procedures for providers.
• 3:41
  SPEAKER_00: And we want to ensure that our patients are first and foremost taken care of in a safe and expedient manner.
• 3:48
  SPEAKER_00: But we also need to make sure that our own team members are taken care of.
• 3:52
  SPEAKER_00: We want to make sure that our members are healthy and can maintain caring for a lot of patients.
• 3:58
  SPEAKER_00: The other area that has been a challenge for us as a specialty is how to address a patient who is coding and ensuring that everybody in the room, not only us as anesthesia providers, but the restorated therapists and the nurses all have adequate PPE for that room.
• 4:16
  SPEAKER_00: Because as we know, some of the healthcare providers in early responses to the COVID crisis here in the United States haven't had adequate PPE and would subsequently become ill and even died.
• 4:28
  SPEAKER_01: Yeah, I think you know, we've really struggled with that as well.
• 4:31
  SPEAKER_01: The majority of our patients are either had never been tested for COVID because it was not suspected, or they were tested but were negative.
• 4:38
  SPEAKER_01: And so when we're dealing with intubations of those patients, you know, I think it's been challenging to work with.
• 4:45
  SPEAKER_01: We understand that anesthesia being right there at the airway, you know, is going to be using an N95.
• 4:52
  SPEAKER_01: But, you know, we've been trying to balance that with supply and that, you know, are there other ways that we can mitigate risks to the other people in the room so that we don't have to have them all wearing N95s when that's not a sustainable strategy?
• 5:05
  SPEAKER_00: Yeah, exactly.
• 5:06
  SPEAKER_00: And I think that, you know, when you talk about that, there's a whole lot of innovation that's gone on.
• 5:12
  SPEAKER_00: And I think that understanding what that innovation is and how to rapidly get some of these innovative ideas into the healthcare workspace while at the same time balancing safety and science has always been a challenge.
• 5:27
  SPEAKER_00: And in this time, it's as big of a challenge as ever.
• 5:30
  SPEAKER_01: Could you maybe talk about some of those innovations that you've utilized at Emory?
• 5:34
  SPEAKER_00: Well, at Emory, the two innovations that I would say one has definitely been a game changer, and the other has been an interesting evolution.
• 5:42
  SPEAKER_00: The game changer for us, the innovation has been in reprocessing N95 masks.
• 5:48
  SPEAKER_00: And I think that for us, just like everywhere else, we realized that for the volume of patients and for the acuity of patients, we were certainly going to run out of the N95s.
• 6:01
  SPEAKER_00: And so very early on, we reached out to Georgia Tech, which is here in Atlanta, and they have a great material science program, a biomedical engineering program, and they worked with us to identify ways of reprocessing the N95s.
• 6:17
  SPEAKER_00: So very early on, we were adopting that, and N95s quickly stopped being one of our big concerns for our nurses and all our staff, not just anesthesia folks.
• 6:30
  SPEAKER_00: The other innovation which I think has been interesting for us is intubating boxes.
• 6:36
  SPEAKER_00: And to describe that for anyone who doesn't know what those are, folks have presented these ideas of plexiglass boxes with a couple of armholes, and you then would capture aerosols inside the box and decrease exposure to folks in the room.
• 6:52
  SPEAKER_00: And again, working in collaboration with Georgia Tech, Emory developed a box that actually had arm sleeves in it to help decrease the aerosols that are blowing up through those holes and into our phases.
• 7:05
  SPEAKER_00: And they also developed uh hinges and other appliances on these boxes to be able to make it a little bit more user-friendly, allow it to be cleaned, and gain access to patient emergency.
• 7:17
  SPEAKER_00: Now, I do have to put a little asterisk around this box because I think there are some drawbacks to it.
• 7:23
  SPEAKER_00: Personally, I think that at times it can be clumsy if you've got an unanticipated difficult airway.
• 7:29
  SPEAKER_00: It may not work in the fashion that you would like it to.
• 7:33
  SPEAKER_00: In addition, I think there's some questions about really how much is it truly protecting folks in the room.
• 7:39
  SPEAKER_00: So at the end of the day, I think we do need to study the box and understand it.
• 7:43
  SPEAKER_00: But I do think it's a great example of collaboration between the clinicians at Emory and the engineers at Georgia Tech?
• 7:50
  SPEAKER_01: Yeah, that sounds great.
• 7:51
  SPEAKER_01: I mean, we also have trialed a box.
• 7:53
  SPEAKER_01: It did not have the hinges that you described, and maybe that's one reason why our anesthesiologists were not as keen on it.
• 7:59
  SPEAKER_01: But uh I think that, you know, certainly there's lots of different potential modifications and constructions that need to be studied, certainly.
• 8:07
  SPEAKER_01: Other than what we've already talked about, how else have you modified your practices around intubations at Emory?
• 8:13
  SPEAKER_00: Well, one of the internal innovations that we've done is we actually identified that we need to have intubation teams made of anesthesia professionals.
• 8:23
  SPEAKER_00: So an attending physician anesthesiologist is the leader of the team, and that person is going to be the one doing the intubation.
• 8:32
  SPEAKER_00: And then we utilize anesthetist.
• 8:34
  SPEAKER_00: So for us, it's a combination of CRNAs as well as anesthesia assistants who then are outside the door, ready to come in to lend a hand, or can also be runners to obtain additional supplies.
• 8:47
  SPEAKER_00: We have been intubating patients early in respiratory distress before things start really going downhill.
• 8:54
  SPEAKER_00: And that's allowed us time to put on our PPE appropriately.
• 8:59
  SPEAKER_00: And we've really encouraged everyone to have strong checklist adherence.
• 9:03
  SPEAKER_00: The other thing that we have been doing at Emory is as we're turning the lights back on and starting to reassess where we are with time-sensitive cases and some of the more elective cases, we're trying to take a longer-term approach to some of our perioperative logistics.
• 9:21
  SPEAKER_00: So previously, we didn't really have a system-wide approach to our perioperative testing, our pre-admission health screening across all of our hospitals and across all of our surgery centers.
• 9:31
  SPEAKER_00: And what's happened is COVID-19 is really causing us to rethink how we approach our pre-op testing.
• 9:37
  SPEAKER_00: Specifically, we're looking at it, trying to ask ourselves how can we do this in a more patient-centered approach?
• 9:44
  SPEAKER_00: For example, you know, as a lot of other medical professionals have discovered, our patients love telehealth.
• 9:51
  SPEAKER_00: And it's a big patient satisfier because they're not having to wait in the Atlanta traffic and drive to a hospital might be an hour away.
• 10:00
  SPEAKER_00: And so they're able to do that.
• 10:02
  SPEAKER_00: And we're now working to expand our screening ability for lab tests at some of our other facilities so that if a patient's haven't surgery in the south part of Atlanta, but they live in north part, they can get their uh tests up at a facility that's more convenient for them.
• 10:18
  SPEAKER_00: So, you know, I think we're changing how we deliver health care for after when COVID is there, uh, based on sort of lessons learned.
• 10:27
  SPEAKER_01: Yeah, and we're finding the same thing around telehealth, especially.
• 10:30
  SPEAKER_01: In terms of the actual intubation practice, have you modified any of your procedures compared to what you did pre-COVID?
• 10:37
  SPEAKER_01: And then also, what about other AGPs like extubation?
• 10:41
  SPEAKER_01: Do you handle those any differently?
• 10:43
  SPEAKER_00: Yeah, that's a great question.
• 10:45
  SPEAKER_00: So, on a personal note, I and many other anesthesiologists have switched from doing what we call a modified rapid sequence induction, where you would titrate your induction agent like propofol in and mass ventilate the patient and then push a neuromuscular blocking agent followed by an intubation.
• 11:04
  SPEAKER_00: So that would be pre-COVID.
• 11:06
  SPEAKER_00: And I've changed my practice so that I'm performing a rapid sequence induction on almost everybody if their airway is reassuring.
• 11:14
  SPEAKER_00: And on one hand, it's potentially less hemodynamically stable.
• 11:18
  SPEAKER_00: At the same time, by not ventilating the patient prior to placement of the endotracheal tube, I'm probably generating less aerosol.
• 11:26
  SPEAKER_00: So that would be something clinical that I'm doing there.
• 11:30
  SPEAKER_00: Extubation has been an interesting problem because, you know, intrinsically coughing is part of excavation.
• 11:38
  SPEAKER_00: And, you know, I certainly feel that excavation is much riskier for all the providers in the room.
• 11:44
  SPEAKER_00: With that in mind, we've been promoting having something covering the face or utilizing the box for the excavation process to try to decrease the amount of aerosol exposure for everybody in the room.
• 11:57
  SPEAKER_01: Great, thank you.
• 11:58
  SPEAKER_01: What opportunities do you feel that there are for individuals working in healthcare Epi and hospital medicine to work together to handle the pandemic long term?
• 12:07
  SPEAKER_00: Well, I think first is, you know, I think the dialogue that occurs between Healthcare Epi and all the stakeholders within the hospital is to understand and communicate and educate everybody on the supply chain constraints.
• 12:22
  SPEAKER_00: Because the thing is, is that, you know, everybody wants to be safe when they come to work.
• 12:26
  SPEAKER_00: And I don't think everybody comes to work thinking themselves like, hey, I could die taking care of my patient.
• 12:33
  SPEAKER_00: COVID-19 has really brought that to the forefront.
• 12:36
  SPEAKER_00: And the fear that a lot of our staff and fellow physicians have, I think really emphasizes that need or the desire for protection and what have you.
• 12:46
  SPEAKER_00: And yeah, obviously, we can't all dress in spacesuits 24-7 at work.
• 12:52
  SPEAKER_00: You know, I think that there's opportunity for additional innovation in PPE.
• 12:57
  SPEAKER_00: So one of the things I've wondered about is increasing reusable respirators and making them more patient-friendly.
• 13:05
  SPEAKER_00: You know, a lot of times when some of my colleagues who are doing signage surgery are wearing, and you know, they sound like a Charlie Brown character where hey, pass a scalp off, you know, and you can't understand what you're saying.
• 13:19
  SPEAKER_00: So, you know, I wonder what what types of innovations and equipment may come about.
• 13:25
  SPEAKER_00: And ultimately, those innovations are going to come from all of us working together.
• 13:29
  SPEAKER_00: You know, again, on the innovation, I've been really fortunate, or Emory's been really fortunate, because my partner on the surgery side and our hospital epidemiologists have actually been working extremely closely over the last couple of years on other projects.
• 13:46
  SPEAKER_00: And our strong relationships actually really allowed us to quickly move forward on a lot of our crisis pain points because we've really had those relationships to trust each other's expertise and perspectives to be successful.
• 14:00
  SPEAKER_00: And I feel really fortunate to have such a great team.
• 14:03
  SPEAKER_01: That's great.
• 14:04
  SPEAKER_01: And I think, you know, one of the things that we are working through is, you know, we our current practices is our anesthesiologists respond to all intubations or codes on our COVID units, but on the non-COVID units, it may be respiratory therapy, it may be a resident team or intensivist, the RRT team responding to the code.
• 14:24
  SPEAKER_01: Do you have any thoughts about kind of expanding some of the practice changes that you've mentioned earlier to non-anesthesiologists?
• 14:32
  SPEAKER_01: And is that appropriate?
• 14:33
  SPEAKER_00: You know, I think a lot of it is going to be uh hospital and situational dependent.
• 14:38
  SPEAKER_00: I do have a little bit of concern about that in the realm of, for example, physician anesthesiologists are good at not only placement in the tracheal tube, but also managing complications related to the intubation and how it may have interacted with the patient's underlying disease.
• 14:58
  SPEAKER_00: And one of the things that we have needed to address within our system is when you're working with ancillary health providers, they don't necessarily have that expertise on how to deal with these complications.
• 15:12
  SPEAKER_00: And so you end up having some patient outcomes that you don't necessarily want.
• 15:18
  SPEAKER_00: I think that at the end of the day, it's going to be interesting because, you know, during this entire COVID crisis, you know, for example, at Emory, all the anesthesia staff are salaried.
• 15:29
  SPEAKER_00: And since we decreased the number of operative cases by about 70%, we had a lot of people who were relatively underemployed.
• 15:37
  SPEAKER_00: And so we've had the luxury of be able to have teams doing intubations.
• 15:44
  SPEAKER_00: We also had teams that were in the emergency rooms, putting lines in patients as needed and helping out.
• 15:51
  SPEAKER_00: And also we use some of our nurse practitioners and our residents in the ICUs as additional staff there.
• 15:58
  SPEAKER_00: So, you know, as the lights get turned back on, we're having to answer the questions of how do we redeploy people effectively and maintain the high level of care that we've provided for the last two months.
• 16:09
  SPEAKER_01: Yeah, everyone's probably been spoiled having your highest level intubators all around.
• 16:14
  SPEAKER_01: Great.
• 16:14
  SPEAKER_01: Do you have anything else you wanted to add in terms of future changes that you see happening that you haven't mentioned already?
• 16:20
  SPEAKER_00: I think moving forward, one of the things that COVID has also done is it's brought a lot of teams together and broken down a lot of the silos that previously existed between specialties.
• 16:31
  SPEAKER_00: And so I'm really hopeful that many of our specialties can work more closely together to improve healthcare for all of our patients.
• 16:39
  SPEAKER_00: And, you know, I think bringing the infectious disease folks, epidemiologists into a perioperate environment can only help all of us because I think the ours provide a great opportunity for, you know, infection control, you know, SSIs, CLABSY, CODI, all the all the hacks, but also increasing our staff safety as well.
• 17:00
  SPEAKER_01: Yes, I really couldn't agree more.
• 17:02
  SPEAKER_01: With that, I think we're going to close out this podcast.
• 17:05
  SPEAKER_01: Thank you very much to our speaker, Dr.
• 17:06
  SPEAKER_01: Grant Lindy, for joining us today and sharing your perspectives.
• 17:10
  SPEAKER_01: A sincere thank you from Shay to all healthcare personnel for all that you're doing to respond to COVID-19.
• 17:16
  SPEAKER_01: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 17:23
  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.
• 17:36
  SPEAKER_01: That concludes this episode of the COVID 19 Allies and Infection Prevention Podcast series.