Adult Surviving Sepis Campaign Guidelines (Hour-1 Bundle)
Children's Surviving Sepsis Campaign Guidelines
Adult ICU Liberation Guidelines and Bundle (A-F)
Management of Adults with COVID-19
New User? Sign Up Free
SCCM is updating its SCCM Connect Community. Access to SCCM Connect may be limited until April 23.
Planning is part of the core DNA of the disaster/mass casualty community. Some of us have made it an academic focus.1 Plan and prepare, simulate and train, in a continuous quest for quality improvement, sometimes on a large scale. We never know what might be coming, except that it is coming, so there is a need for foresight and imagination in the planning process.
Preparation has always been a personal focus. It was the subject of my 2005 presidential address to the Eastern Association for the Surgery of Trauma,2 and my 2008 Society of Critical Care Medicine (SCCM) presidential address. In order to prepare and lead, whether your institution or your team, it is important to understand yourself: how you work, how you learn, how you teach, how you interact. Few people are instinctive natural leaders, but we can learn and become skilled. If leadership is not a role you hold or seek, you can prepare to be an engaged, valuable team member.
There are two aphorisms that I teach my trainees: “It is easier to keep a patient out of trouble than to get a patient out of trouble,” and “If you think two steps ahead, you can act one step ahead.” These principles have served me well throughout a long career as an acute care surgeon (trauma, emergency general surgery, surgical critical care), and in responding to three mass casualty incidents in New York City: September 11, Hurricane Sandy, and the U.S. epicenter of the novel coronavirus 2019 (COVID-19) pandemic. Each was unique, and all taught us much. This essay is about our response to the most recent, ongoing catastrophe.
Planning and preparation began in early March when the first few cases were presenting for hospital admission. We knew trouble was brewing and began planning for conversion of clinical spaces into temporary ICUs and for redeployment of staff, but nothing was concrete. In retrospect, it is quaint to reflect on how little we knew about the disease just a few weeks ago—or what would be required of us. Imaginative planning, some of which had to happen on the fly, carried the day. In strategic planning parlance, scenario planning envisions the worst-case scenario, and then imagines it to be even worse than envisioned so as to plan accordingly.
Scenario planning came to the rescue of SCCM in 2005 in the aftermath of Hurricane Katrina, when I was on the SCCM Executive Committee and the Strategic Planning Committee. Our Critical Care Congress was scheduled only four months later and needed immediate relocation from the inundated Ernest N. Morial Convention Center in New Orleans. The catastrophic loss of our convention venue had been planned for in advance, and SCCM was able to relocate within hours to the George R. Moscone Center in San Francisco despite substantial competition from other displaced organizations. Scenario planning would prove instrumental for pandemic response planning as well.
From zero cases of COVID-19 in New York State on March 4, there were more than 7100 cases by March 20, with nearly 2000 new cases each day. As of this writing (May 12, 2020), confirmed New York State cases number 338,485, with 1430 new cases today.3 Statewide, deaths number 21,845, with 205 new deaths. For New York City, the data are 186,123 total cases (55% of the state total), 766 new cases (54%), 20,237 deaths (93%!), and 181 new deaths (83%). The exponential increases in cases and deaths underscore the enormity of what was asked of us, institutionally as well as personally.
By executive order of the governor of New York State, all hospitals were ordered to double the number of available adult intensive care beds, from 114 to more than 250 ICU beds total in our facility. In response, elective surgery ceased on March 14; operating rooms, postanesthesia care units (PACUs), and step-down units were transformed to function as temporary ICUs, and hundreds of noncritical care staff members were trained to collaborate with critical patient care. Authentic ICUs were charged with managing the sickest patients. Modifications (e.g., physicabarriers, upgraded ventilation and electrical power) were required to convert operating rooms,4 PACUs, and medical-surgical floor units into temporary ICUs. Our sense was that we had little time to prepare;5 we were correct—we had about one week. One thing we did not expect, and could not plan for except in near-real time, was how often and how dramatically our service’s mission would change in the space of a few days.
By March 23, the surgical ICU had been designated as the non-COVID-19 medical-surgical ICU for all comers. Our two virus-positive patients were transferred out, and we received numerous admissions from just about every other ICU as the other units began cohorting COVID-19 patients, who then numbered about 35. As we predicted at the time, that lasted only until the COVID-19-designated authentic ICUs, which were then basically all of them except the surgical ICU and adjacent burn unit, reached capacity. That took two days.
The flood of COVID-19 patients via the emergency department began on March 25, just as we had emptied our unit a second time into our burn unit, the then-current designated non-COVID-19 medical-surgical ICU. The burn unit census at the time was 11 patients, five of whom had burns. Only four of the 23 rooms in our main operating suite still functioned as operating rooms; the remainder had been transformed into a large (40+ bed) temporary ICU. Emergency general surgery had almost ceased because people were staying away from the hospital in droves for fear of contagion, and those who did present were managed nonoperatively insofar as possible (e.g., acute appendicitis and cholecystitis). Trauma volume plummeted as people stopped driving under stay-at-home orders and the bars closed. Noncritical, non-COVID-19 patients were moved across the street to our orthopedic specialty hospital. Pediatric patients were transferred to another children’s hospital in our network. We were transformed into a several-hundred-bed adult respiratory intensive care hospital. In our latest role, we received 19 new, unstable, ventilated COVID-19-positive patients in less than 24 hours. One negative-pressure room was reserved momentarily for respiratory procedures such as intubations, bronchoscopy (avoidance was encouraged owing to potential aerosolization of viral particles) and tracheostomy (also to be avoided). That did not last long either, as admission number 20 was accepted within hours. That was one hectic day.
Our mission as surgical intensivists, once definitive, was manifold: to care for numerous critically ill patients while learning about the new and unique COVID-19 syndrome; to train, inculcate, and incorporate colleagues with limited or no critical care experience to provide care to these patients; and to revise existing protocols and create new ones to standardize critical care across multiple temporary ICUs as they opened to receive patients, and to which we (correctly) anticipated redeployment. Our task was confounded by the unstable, rapidly changing nature of these new patients; yet, given their remarkably similar presentations it could become difficult to keep track.
Moreover, arterial blood gas determinations often exceeded 100 tests/ unit/day. This, combined with the need to follow a battery of other biomarkers that are of prognostic value in COVID-19 but otherwise ordered infrequently (e.g., procalcitonin, D-dimer), added to the density of data capture and the potential for confusion. It was necessary to fundamentally transform what and how we communicated. The need became apparent immediately for a simple system of patient classification that would be useful for triage, communication, and resource allocation (should it have become necessary; fortunately it did not).6 A visual tool, analogous to a dashboard, was also created to facilitate rapid, accurate transmittal of crucial information, even to clinicians coming to the ICU bedside for the first time.7 After a 48-hour trial period, both innovations were adopted hospital-wide and remain in use as of this writing.
At the peak, which occurred about April 15, 10 temporary ICUs were caring for 211 critically ill ventilated patients with COVID-19 in addition to the authentic ICUs, with medical care provided by anesthesia, medical, pediatric, and surgical intensivists. (Across the network, peak workload was 733 ventilated patients.) To cover our service responsibilities, including 54 critical care beds in three ICUs (one was a temporary unit in an ambulatory surgery facility across the street), trauma, emergency general surgery, and burns, the surgical service redeployed with 12-hour shifts around the clock, five days on/two off. Each of our ICU teams had a surgical intensivist, an internal medicine hospitalist, a surgical critical care fellow, one physician assistant, and four residents, whether from anesthesiology, general surgery, neurosurgery, oral surgery, or plastic surgery. Three board-certified surgeons (two with surgical critical care certification) returned “home” from other institutions to serve as volunteers, providing invaluable coverage of the call schedule. Our chief of breast surgery, an individual experienced in talking with patients and families, volunteered to assume responsibility for daily communications with families (a crucial task considering that patient visitation was suspended), freeing up bandwidth for the intensivists to provide patient care. Several team members became ill themselves. The ranks of physical therapists and dialysis nurses were depleted by numerous cases of COVID-19; for them it was a scramble to provide coverage. Our clinical pharmacy manager, also out sick with COVID-19, performed yeoman service by making daily rounds by telephone. Heroes, one and all.
Now post-peak, even as we continue to care for these patients, the planning and preparation continue, to restore hospital services and resume business as usual. When will New York City reopen? We still have but four operating rooms functioning as such, but access to them is now becoming less restricted. Acute care surgical volumes are recovering as people overcome their fear of coming to the hospital. As of today, we can operate again on uncomplicated acute appendicitis or cholecystitis if indicated. Elective surgery is another story. Soon the operating rooms and the PACUs will be restored, and we will be ready. The backlog department-wide is hundreds of cases. Will we be enabled? That decision will be as much political as medical.
Criteria as to when New York City will normalize are heavily oriented toward medical indicators.3 New York State set seven criteria statewide, four of which are met currently in New York City. We have had a 14-day decline in hospitalizations and deaths. More than 30,000 tests/100,000 population have been performed in the past 30 days, and more than 30 contact tracers/100,000 population are working.
Criteria not met as yet are for new hospitalizations to be fewer than 2/ day/100,000 (currently 2.67), the proportion of hospital beds available to be more than 30% (currently 28%), and proportion of ICU beds available to be more than 30% (currently 24%). Two of three additional New York City criteria have been met: Hospital admissions are fewer than 200/day, and the proportion of new, positive nasal swab tests is less than 15%, but there are still 550 critical care patients in the hospitals operated by the NYC Health + Hospitals Corporation, and the number needs to be less than 375. Close, but how close? Critically ill COVID-19 patients do not recover quickly. Until that day, we plan and prepare for the future and continue to look after the 24 critically ill COVID-19 patients still in our care.