Hello, good morning. My name is Karla Venegas-Borsellino. I'm a critical care medicine physician at Mayo Clinic Florida, and I will be moderating the next session on distinct critical care leadership experience during the COVID-19 pandemic in the southern states. During this session, we will be describing distinct leadership while interacting with other multi-professional leaders in different hospitals that comprise a healthcare enterprise during the COVID-19 pandemic. We will delineate crucial interactions in effective critical care leadership without being a named service line chair of enhanced responsiveness during the COVID-19 pandemic, and demonstrate the critical role of the advanced practice provider leader on fluid care models during the COVID-19 pandemic. For this session, we come with the participation of great leaders and experts in this area at the national and international level, and in the name of the SCCM community, we hope you enjoy this session and welcome all your questions at the end. Thank you. Good afternoon. This is Jay Pat Hurley. I'm Baylor College of Medicine, Baylor St. Luke's Medical Center, Houston, Texas. I'm here to talk to you about distinct critical care leadership during the COVID-19 pandemic southern experience. So let's get right to it. You've all seen these graphs. This is COVID-19 hospitalizations over time through the United States. So we all saw the surge in March and April, we saw a second surge in the summer, and we're in this surge here, number three, as we call it, surge three in Houston. The mortality, this slide mirrors that, of course. This slide here is local data. So this is what happened to us in Houston. This is from the Texas Medical Center site. It's a great site that presents data every single day on COVID, our case number, our hospital number, et cetera. I'll show you more data in a minute on that. But here in March and April, we got a little taste of COVID, but the big taste was here when we had our major surge, surge two, as we call it. And so most of our experience came from surge two. Now time for lessons from Washington and New York City. So we were a couple or so weeks behind Washington State and New York City in terms of surge one when the pandemic hit us in March and April. So we had a couple of weeks to prepare. Now that is distinct, or that distinguishes us here in the South or in the Southern states from, of course, Washington State and New York City. We had time to prepare, certainly more time than Washington State and New York City. And we really did take advantage of that. So that was a distinct experience. We had much more time to prepare than they did. Now my contacts in Washington, my contacts in New York, I called them, I talked to them, I emailed them. The one important thing they told me was prepare, prepare, prepare. So their experience in both Washington State and New York City was, is that the pandemic started as a real slow drip of patients and then quickly and logarithmically escalated into a tsunami, a tidal wave of patients. So I was advised and certainly had a little bit of time to prepare well for this volume influx of patients. So the Southern experience was helped, I think, by the Washington State and New York City experience. So we had time to prepare unlike they did. We understood from them that this would likely start slow and quickly escalate. And as you saw from my data several slides ago, we had a little surge initially in March and April, but then this big surge in the summer, June, July, August, mimicked that experience in Washington State and New York City. In other words, we started very slow and quickly escalated in terms of volume in our institution in Houston, Texas. So of course, preparing, I won't go into all the data and details on this, but the elements of preparation, I think everybody knows by this point, space, staff, PPE, equipment, command and control center. One of the things that we learned from Washington State and New York City, but we really learned it as well from our local experiences, is that modeling surge volume really, really helped us in planning. So we learned from Washington, we learned from New York that planning volume surges is important, but our data capture and data analysis live time, and in Houston, we use the Texas Medical Center data analysis team to set up daily volumes and projections of what was going to happen to that volume over time in our medical center, and that really helped us to plan. It helped us plan with PPE equipment, it helped us, of course, at the command center level to coordinate that, it helped us especially to plan our staffing models. So, this is actually similar data from the slide I showed you a minute ago. This is now May, this is a big surge. By Labor Day, we had cooled off, and then, of course, we're in surge three, we call it. We're slowly isolating here in the medical center as they are around the country. This is more data from the TMC website. This is data on hospitalizations and ICU beds. Again, data like this, a data analysis team, we were very fortunate, our Texas Medical Center data analysis team provided us data from Houston and Harris County. Houston sits in Harris County as to what the testing positivity rate is out there, what the hospitalization and ICU rate is out there, and that really helped us plan. So, prepare and plan is critical in this pandemic, and data analysis and data projections that really helped us, or really did help us at that time, continue to help us. And, of course, with that, we produced this, the effective reproduction rates, so we have an idea, is this thing waxing or waning, and at what speed? So data analysis is very important in planning. Now, I particularly being the chief of critical care, one of my tasks, of course, is staffing. So there are many elements to planning, space, as I mentioned, equipment, supplies, et cetera, but staffing is really critical, and so this is something like what our staffing model looked like that I created. We had yellow, orange, red, these are ICU beds, obviously, so the number of beds per surge level, so at the entry level, yellow, orange, red, 148 beds. Now, at each of these levels, there are very detailed staffing plans. It's very important in our experience, or it was helpful, very helpful in our experience, that we had detailed staffing plans for every level of this pandemic surge. While we were doing that, by the way, we were managing the traffic of the other non-COVID patients, but understanding the surge volumes helped us to develop staffing models for different levels of different volumes during the surge. So this really allowed us to open ICUs quickly, and on the backside, by the way, close ICUs quickly, we understood the speed at which the volume was escalating so that we could stay one step ahead, meaning one ICU ahead. Ultimately, at my institution, we opened a total of five ICUs, and we opened a very large IMU, but understanding the data analysis, and specifically the volume projection, helped us to stay ahead in terms of space planning, equipment planning, supply planning, staff planning. So we opened units serially very quickly. The facilities folks, supply and equipment people were very adept at setting up units quickly and supplying them and providing the proper equipment. These teams that we set up before the units opened, it was very important to have these teams set up, have these teams set up in detail, have these teams know who each other were, and by the way, we did use the Society of Clinical Care and Medicine training course for hospitalists, which gave our hospitalists who were included in some of these ICU teams a lot of confidence. That helped, of course, when we hit peak surge and space started becoming restricted, then of course we held our elective procedures. Our command center was very important in this process in opening and closing units. They helped to coordinate all the disparate elements of opening and closing units. Obviously, I dealt with the medical staff, but there are nursing staff issues, respiratory staff issues, multiple staff issues, equipment and supply issues, but again, having that data and using data analysis to know when to open units and then having a command center that helped to integrate everything that was needed to open these units as a surge was mounting and then actually in the back end to close these units serially was very, very helpful. So, that's one experience from the South was we learned to prepare and we learned to use data to prepare for the surges, especially in terms of volume. Now, one of the challenges of this pandemic was trying to manage the flow of information. This is not unique to us here in the South, but data was coming at us like everybody from the lay press, from colleagues. We actually set up a WhatsApp chat group that had over 200 members, doctors, nurses, perfusionists. We all saw a flurry of newsletter updates from JAMA or the Mass General or email box every day. Expert bodies were coming out with updates on their standard recommendations. The Society of Critical Care Medicine had expert chats periodically, which I found very, very helpful. So, that was a helpful tool in terms of live time chats to communicate and discuss updates. A lot of articles came out of preprint servers, non-period surge. So, how do we keep up with this flow of information and how do we integrate this flow of information into procedures, protocols, processes, and pathways? And what we did here, at least I think one of the leadership lessons here is that we used the wisdom of the crowd. So, of course, for specific tasks, and I'll show you some of those specific tasks, we divided our medical staff, respiratory staff, or whoever was involved in that specific task up into teams. They wrote down protocols and they also drilled on those protocols. I'll show you that in a minute in another slide. But what was really helpful for us is that we had a weekly Zoom meeting that really ran out of critical care. You know, the critically ill patients landed in the ICU. So, I think the critical care doctors may have been the most invested of all the docs in the hospital in proper care of these patients. But at any rate, so we had weekly Zoom meetings that included our critical care leaders, but also ED docs and hospitalists who saw these patients before they got to us. Very important to include them in this process. Infectious disease experts, of course, at our institution, and the Baylor College of Medicine, infection prevention leaders and workers were involved in these meetings. And leaders from all these services involved in taking care of these patients. Nursing, exercise, physiology, nutrition, pharmacy, social work. Now, from the experience data and review of the literature, we developed our own protocols and we iterated those protocols over time. We learned to put them on our desktop computer. When you open our desktop computer, you open to the source. We had something called COVID-19 Resource Center there. And that's where all our protocols were for. Now, some of the protocols were very, very specialized in tracheal intubation, traching, proning, bronchoscopy. So these specialized teams developed protocols and drilled on them. And we have very nice training facilities, high-fidelity training facilities that really helped us through that process. Now, keeping up with evolving literature protocols, I found this NIH website very helpful. I think as many of you did, we were an NIH study center. So it was helpful for us in general to keep abreast through this website. I found the NIH's Fast Track Area 1, 2, 3, 4 to be fascinating sites that helped us understand how basic scientists identified potential interventions, either from basic knowledge databases or artificial intelligence sometimes, all the way up to experts in developing and deploying clinical trials. It was very helpful for us to keep up with this website in terms of what is happening out there. This is a website that kept track of the adaptive trials for COVID-19, the ACT trials, very cleverly designed trials, multi-arms that could roll up or down, very important for us to keep track of those trials. So that's a way we, in addition to the weekly meetings we had and the other things I mentioned, keeping up with the NIH through this website helped us. This is a clever website set up by Stanford. They basically showed us all the trials going on with all the different types of interventions. They put them in categories and even weighted the trials in categories. So the NIH websites, the Stanford websites helped us keep up with all the information flowing. Now let me come to lessons. So some of the practical lessons of leadership during COVID, and I just want to emphasize that I'm not, I would not call myself an expert leader. I would not call myself a well-trained management expert, but these are some practical lessons I learned along the way. Your work staff has to understand that safety and health of the team members is a real priority for you if you're a leader in critical care. You need to be in the trenches. That was very important. I was in the first ICU that opened so that I could see live time what was happening and adjust on the fly. Leaders need to be seen. Leaders need to be heard by the workforce. It's very important as a leader to communicate clearly your mission, your purpose, and the importance to the community. It's very important as a leader, I learned, that to make the plan clear and disseminated frequently and clearly. It's very important as a leader to develop critical care as a team sport and to send that message. Every member of the critical care team should be empowered. Every member should have a voice. And of course, communication during times of pandemic or any crisis is critical. Lines within the different services that led up to the command center are very important. And the command center, of course, is critical. So communication, very important along the lines of the service, all the way up to the command center. And technology was very helpful for us. We used TigerText. The texting platforms or similar type rapid communication platforms were helpful. This is mortality data. I'll walk through this very quickly for you. This is what our mortality data looked like at Baylor St. Luke's. We started out here. We ended up here. And for the last several months, we've been in the 10 to 12 range. This data looks a lot like, pardon me, this data looks a lot like data from New York City. This is from Langone. They started out in the mid-20s mortality. They ended up in the 10 to 12 range. And around the world, from high-functioning ICs around the world, mortality in ICs started at a high. It sort of landed in the 30 to 50 range. This is data from the United Kingdom. They improved their ICU mortality over time. We are a little bit stuck in terms of ventilator mortality. This is another paper published late August, early September. International ventilator mortality 43%. Our data, about 40%. Some institutions, Mass General, Vanderbilt, Emory, reporting excellent outcomes in ventilated patients. But I think, as everyone knows, early in the pandemic, we intubated patients early. We did that more for the protection of our providers. We did not want a calf sprain, as we say in Texas, when it was time to intubate. So we intubated early. Most institutions throughout the United States, though it's interesting there's not been much written on this, most institutions have gone to intubating less, intubating later, and only really after we tried high flow and other non-invasive means. So we, as a group in critical care, I think evolved to a point where we're intubating later, less often, and less frequently. But this slide here, lessons that we've learned, and why has locally and why has internationally we've improved in ICU outcomes. So let's talk about that for just a minute. ICU outcomes, why are they better? Is it because the populations are different? Are they younger? Are they different? Epidemiologists are saying no. Is the virus less virulent? No. Is the inoculum size less or the inoculum volume less? Maybe social distancing, masks. Maybe patients are getting less inoculum. But I think we're getting better in the ICU because of team function. Some of the treatments are offering advantages. Certainly the steroids have helped. That's something nobody will disagree with, I think. But I also think that we've gotten better as teams in the ICU, as services in critical care, and as institutions, even as hospital systems, and as a nation, to support our ICUs and help those ICU teams improve. We still need breakthroughs, big breakthroughs, in the bad ARDS and the bad cardiovascular shock patients. I'm going to show you three slides of local data that mimics, I think, some of what's happening nationally. We started out with a high admission rate through the ICU but slowly dropped the number of patients admitted to our hospital to the ICU. So ICU admission percentage rate dropped slowly through the pandemic. Our ventilator use dropped slowly through the pandemic. We were using more high flow, more non-invasive means, especially the helmet here in Houston. And then interestingly, our, of course, ICU mortality dropped rather dramatically, just like it did throughout the world. We dropped from about 50% to around 30%. At this time, surge two, we were using sort of standard therapy. This is a list of our standard therapies. I won't go through that. Interestingly, community hospitals really seem to be the red-headed stepchild of critical care. When we talk nationally about critical care, you know, in Texas, Baylor St. Luke's is the home of the 17 hospital system of community hospitals. We're also part of Common Spirit National. So we have a little different perspective. I mean, these community hospitals, you know, they're highly variable. Some of them are mini medical centers. Some of them are critical access. In the south, there are a lot of rural hospitals, a lot of hospitals far away from good resources. So how did we help those hospitals that were very often understaffed with critical care professionals, nurses, therapists, especially doctors? Well, in our system, we set up EICUs in those hospitals using hospitalists as a primary. We had a plug and play model of EICU from our national partner, Common Spirit. These worked very well. The hospitalists as primary, rounding with EICU doctors, consulting with EICU doctors. We had a Scotch tape and bailing wire together, our proceduralists. So airways from the ER or lines from anesthesia or general surgery. But we used the EICU model in our community hospital system that were really being very saturated with these COVID patients. We took as many as we could in the medical center, but in the community hospitals, the EICU was effective. Let's talk very, very quickly about burnout. A big problem for hospitals like ours or any hospital of significant size that takes care of these patients. There's been a lot written about burnout. The Society of Critical Care Medicine has taken that up in the form of the Academic Leaders Group. Thank you very much. We really need to understand burnout. So I would say that burnout really came out in COVID among all levels of providers. In our specific locale, Harris County, of course, physicians with a lot of burnout, but nurses really suffered burnout most among all the providers. We need a lot of research and understanding of burnout. There's a lot to it. You need interventions, but COVID really brought that out. We suffered a lot of burnout. So one of the lessons from this pandemic is we need to learn more about burnout. Some practical lessons I learned about burnout is being out there among the work staff was helpful to them, was supportive of them, getting to them the message that we care about them. We want a safe work environment for them is very important. Leaders care, leaders care for them personally and for their health, very important. Of course, we were careful and thoughtful about rates for our workforce, data feedback to our providers, especially successful and good data really helped our providers. Really this right here has helped us provide, it was a great intervention to help us prevent a lot of burnout. Building community in the unit, in the section, service, hospital, in the Texas Medical Center, but especially in the community. And one of the things I learned in this pandemic is that media, lay media, social media, television, other media forms can really help us to support our frontline providers. They're heroes, they should be called out as such, and that really helped us sustain and helped us with burnout. Some of the keepers from this experience for me is training and team management. Critical care docs are by nature team leaders. We run multidisciplinary teams, we interact with multiple consultants. So by nature we're team leaders, but our standard training of fellows really doesn't include training and team management, process management, systems engineering, understanding the psychology of a team, understanding burnouts. So I think one of my lessons coming out of this is that we need to do a better job of developing leaders in critical care, especially as we know over time, relative to the need, our critical care professional providers relative to the need will stay the same or go down over time. So we really need to develop leadership in our fellows and trainees in critical care, and one thing I do think we do need nationally is we need to be able to cross state lines. Providers do, physicians, nurses, etc. This state licensing shouldn't prevent us from having national response teams, and I think the Society for Care Medicine is well positioned to advocate for that. I'm coming to the end of my talk. This is fortunately my last slide. So this was our experience. When you get ready for a disaster, this is emotional low and high. People are in dread. Everybody goes into hero mode when it hits, and then after the disaster, we all crash physically, emotionally, mentally. We reconstitute for the next surge, and that's been our pattern, surge, surge, surge, and I think that will continue at least until the vaccine can get us to that critical threshold. So some of the lessons we've learned here in Harris County, Houston, Texas, and in the South, I hope that's helpful. Thank you very much. It's been a pleasure speaking with you. Hello, my name is Robert Webster. I'm a Director of Critical Care Advanced Practice at Baylor St. Luke's Medical Center and Baylor College of Medicine. I'd like to thank everybody for coming out to get into these discussions. My topic today is how does APP leadership transcend in fast-changing care models during the COVID crisis? The APP nurse practitioner, physician assistant role at Baylor College of Medicine, the critical care role is associated with providing direct clinical services for critically ill patients. Secondly, to perform comprehensive assessments, assist with making differential diagnosis, ordering tests, procedures, and coordinating and planning patient management. Accountability is extremely important in this role as the APP has to make sound decision-making, interpersonal and communication skills are a must. We provide evidence-based clinical standards that adhere to established protocols. Experienced during the COVID pandemic, the APP workforce required more engagement in governance, management, and leadership at the hospital level. We had to adapt quickly to fluctuating workloads and acuity. APP leadership had to engage in all aspects of health care delivery and had to collaborate with hospital administration and medical leadership in many areas including bed control, equipment and supplies, physical structure, and staff regarding medical and nursing. In the surge capacity, it was defined as a yellow, a orange, and a red surge plan. The yellow surge plan, we had 19 patients with an escalation in the orange to 59 beds, capacity of COVID positive patients, critical care, and then in the red surge plan, we escalated to 148 beds. In doing this, we had to mobilize our APC staff. The mobilization of the APC staff, our focus was on looking at leadership qualities or potentials, the level of experience, skill sets, and the physical conditions of our existing staff. Many of our providers had relative risk factors, including diabetes, hypertension, we had a few people who were pregnant, and other health care issues. We had to identify health care professionals, NPs and PAs within our organization from other areas to see how they would fit into our organization of taking care of patients in a quality manner. We identified skilled health care position professionals, NPs and PAs outside of the organization by way of contractors, bringing in people from the outside, and we brought in approximately 7 to 10 of these people from across the nation. In the yellow surge plan, we had 19 beds. You can see to the left, we had 19 beds. You can see to the left, we had a number of units that we started off. This didn't determine how we were going to determine these 19 beds and what we'll be adding to our current critical care population. The next slide looks at the orange surge plan, and it's a total at this point of 54 beds. We have designated how we would find those beds in the particular designated units. All of these beds would be COVID patients, and it would go up to 54 beds. When we hit the red surge plan, it was the most intensive time because at that time, we had a projection of having 448 COVID beds. At that point, we looked at every area in the hospital where we could add on, including the PACU and the emergency room, adding five beds to emergency room and COVID beds in the emergency room. The clinical conditions. During this period, the census would increase with a level of frequency and fluctuation on an hourly basis. Additional critical care areas to be covered, we went from our average of six critical care areas to an additional six. The continuation of non-COVID caseload was a very key. We wanted to continue to have CT surgery as a referral center and continue to do our scheduled cases. The next thing we wanted to provide coverage for higher acuity and more complex patients in these newly developed units that we had, including ECMO and advanced mechanical ventilation and other interventions that was associated with the COVID patients. From my perspective, we had to maintain APP retention and we had to manage burnout during this COVID episode. Our APP leadership goals is to maintain APP expectations, clinical roles, increase APP critical care experience, assist the hospital and the healthcare system directly, construct new culture, working smarter and harder with our organized medical staff in solving problems. We wanted to improve the alignment with patient care partners, nursing, pharmacy, respiratory care, nutrition, spiritual, and rehabilitative services. And we wanted to focus on hospital quality improvement issues. APP leadership, staff expansion and projects. We did a recruitment as we spoke about early, seven experienced nurse practitioners, physician assistants. We expanded our moonlighting opportunities and we established a part-time and PRN pool. We created an APP vascular access team due to the unexpected CLABSI rate spike, the replacement of the PICC lines and the midline catheters. We serviced a critical care only throughout the hospital. And the goal was to decrease the CLABSI level, which was greater than one and try to bring that level down and also try to provide the service on the same day, in which our numbers were about 98, 97% satisfactory. APP leadership, we did a staff expansion and projects in quality improvement, looking at Foley catheter removals, head elevations of 30 degrees, looked at nutrition and having spontaneous breathing trials on a daily basis. We implemented a rounding and documentation strategies to reduce communication errors, to enhance patient care quality and patient safety, to improve communication and collaboration with consulting services or in our multidisciplinary teams. We tried to improve direct communication and foster collaboration between our APCs and nursing staff, as well as our physician partners. During this time, we made application to Baylor College of Medicine to develop the NP, the PA Critical Care Fellowship Program. This program will provide a comprehensive introduction to the clinical culture of critical care and improving the knowledge of physician assistants and nurse practitioners in critical care or injured patients. We wanted to introduce and broaden the knowledge of nurse practitioners and PAs in looking at conventional disease process, representing critical care physiology, pathophysiology and disease prognosis. When we develop a diverse understanding of differential diagnosis, evidence-based diagnostic treatment plans, and to align with presenting symptoms and implementing cost-effective critical care interventions. We wanted to also increase by implementing this plan to increase critical thinking skills with supervising a structural clinical exposure to critical care patients. In conclusion, the APP team, remember what I learned from this, the APP team members were resilient. They were competent, committed, dedicated, without reference. They sacrificed themselves during the day and isolated themselves from their families by night. They worked in every critical care area in the hospital, continuously exceeding their roles and expectations. They learned that they learned their own strengths, their own weaknesses, and their they learned that they learned their own strengths and weaknesses and dedicated and showed dedication to their profession at all times, which was very commendable. The APP leadership, given the magnitude of the crisis and the challenges associated with this rapidly growing number of patients, as a leader, I learned that immediate focus had to be placed on the physical safety and health of the APP staff. This was done because I realized that any marginal reduction in our workforce would dramatically impact our ability to provide substantial care and safety to our patients. It was also important to maintain an authentic connection with our staff and the physician partners during this crucial time. I wanted to make sure that we presented a very strong front because I realized that any glimpse of uncertainty in leadership would create doubt for the team. It was very important that we keep our team mentally and physically engaged in the process. I would like to thank everybody for joining this discussion today. If you have any questions, please feel free to reach out to me and I will be happy to answer as indicated. Thank you very much for joining in on this discussion. Hello, good morning, everybody. Thank you for joining us in this session in the Distinct Critical Care Leadership Experience During the COVID-19 Pandemic in the Southern States. So now, my name is Karla Venegas-Borcellino, as we mentioned at the beginning. I'm very pleased to moderate this session. And we know that these are different, particularly different challenging times where leadership has been a challenge across the world, really. And our healthcare services have been put on the test sometimes with these difficulties. We apologize, we could not upload earlier the presentation for Dr. Ochoa. So right now, we're going to listen from him from his experience. And we are going to start getting the questions in the Q&A section. And then at the end, we're going to answer all of them. So Dr. Ochoa, thank you so much for joining us. Thank you so much, Dr. Venegas. And thank you all. And my apologies, the technology defeated me a little bit. But I think it is an interesting challenge to give a presentation without slides. And I've had to do that a couple of times in my career. And it actually forces you to be thoughtful about things. So overcoming this technological challenge, I am an SCCM member now for many years. I'm a surgeon by training. I have no conflict of interest to declare. I will be talking about my experience at Boschner Medical Center, where I was the director for the Surgical Intensive Care Unit. But as COVID would have it, we were all involved as a team working together. And that was part of our interesting experiences. I currently do work part-time at Boschner, but I also direct the Intensive Care Unit at Hunterdon Medical Center in New Jersey. Around April, I'm sorry, around February, as we were having and getting messages from different parts of the world, we were all involved in Mardi Gras. And we still were quite unconcerned of what is happening around the world. Early March, we saw our first cases. And within three weeks, by the end of March, by sometimes in April, we had over 2,000 cases in the Oshner Healthcare System of patients with COVID-19. But we had to adapt really fast. And this is a little bit of sharing these experiences. A couple of things that we learned very fast is that age was clearly the most important risk factor. And that those patients that were advancing in age were the patients that we were getting to develop severe COVID and end up in the ICUs. But we also saw something very distressing. And we ended up dividing patients into three different phenotypes. First one was, again, the patients with sarcopenia and old age, generally nursing home residents. Those became a significant portion of the patients that we saw. We also saw a number of patients of varying ages with severe comorbidities, those patients that were in renal failure or had active treatments for lymphoma or other neoplasias, or patients with candidates or after clinic liver transplants or other transplants. But the one group that for us became really concerning was the younger morbidly obese patient. The CDC identified that quite fast and demonstrated that as the most important risk factor for those patients 18 to 49, now not the 65 or older, but 18 through 49, obesity and metabolic syndrome were the biggest risk factor. And unfortunately, we were not immune to that. Louisiana is a state with a high degree of obesity. In fact, according to New England Journal of Medicine study in 2019, over 50% of the population in Louisiana is suffering from obesity and or being overweight. And so that hit us quite hard. Now the Ochsner Healthcare System and the entire state had had the experience going through Katrina years before. And I believe that that cultural and organizational knowledge was extremely valuable for us to be able to rise to the occasion, rise to the challenge and successfully manage these patients. As a little background, Ochsner was founded in the 1940s as a private but nonprofit academic healthcare center. It is the largest nonprofit academic healthcare system in Louisiana. It has around 40 owned, managed and affiliated hospitals and specialty hospitals and over 25,000 employees and 4,500 physicians. And so the mission there of Ochsner is really to serve and to heal and to lead and educate and innovate in healthcare. And that along again with all this knowledge that had been gained through Katrina was very useful. We really, essentially what we did is we rolled up our sleeves. And if you could see a slide, we literally used our chalkboards or whiteboards to start thinking how to mobilize the entire healthcare system to respond to this. And we mobilized everybody from the janitors to the CEO so that everybody played a role. The nice thing and the impressive thing is how much volunteering there was. There was a real swell of saying, of everybody saying, what can I do to participate? And literally I had surgeons becoming technicians to clean dialysis equipment because we were running out of people to clean dialysis equipment. And so that is the degree of volunteerism that we saw. The other thing that happened is that we had to adapt the physical plant to the number of patients. And we had to literally grow intensive care units over 48 hours or just a few days. And so we were able to observe our builders, our architects, our engineers, literally build negative pressure rooms out of nothing over weekends and our IT people to put in computers into these rooms. And it was amazing to see how we were able to build new intensive care units out of literally what we thought were just regular spaces. And it worked very well from that point of view. Now, along with all this infrastructure and preparedness, which went everything again from the physical plant to getting adequate PPE, to having the supply chain rev up and work and help us, came a significant challenge about knowledge. And the absolute truth is, we didn't know what we were facing and we had to learn very fast. And so what happened was that we unified, particularly at the leadership of the critical care groups into one and we had daily meetings where we would discuss what we had learned during that day and try to get as much information from other groups coming particularly from Italy at that point, but also from Seattle and from New York City as to what was being learned. And we learned very fast that the pictures of respiratory failure that we were seeing were just not simple ARDS, but that they were really two phenotypes as were described by Luciano Gattinoni very fast and very early in Italy, where we had this L and H phenotypes, one with normal compliance, a very low water concentrations or not heavy lungs that still developed a significant alterations in P2F ratios. And then the H phenotype, a more very, more classic form of ARDS, but that we demanded and the patients demanded a differential management according to the phenotypes that they were showing. We also saw that very early on and through the leadership, the research leadership with Dr. Leo Oswani at Ochsner saw that there were significant issues with minorities and rapidly published that in the New England Journal of Medicine showing how race made a significant difference and that there were other comorbidities that made a significant difference. And so we contributed as an institution and as an organization to the knowledge. We continue to produce, and I was going to show you some data right now that we have developed along with Emory and LSU on immunosuppression and T cell dysfunction, because I cannot show you graphs, I'm not going to go into the details of this, but we now have some really important data and have actually submitted this for grants and submitting it for publication. So we continue to produce quite significantly. So in summary, we have many lessons learned with COVID-19. We were quite prepared as a healthcare system to respond. It did take a little bit of, there was a little bit of a shock on how fast we got into the first wave of patients and how overwhelming this was, how we all had to change our practices very fast, but how the system was able to respond to this incredible amount of pressure. I did not talk about the second wave. By that point, we were far better prepared and we were able to not disrupt the practice of seeing patients without COVID that still, of course, needed our help. Suffice it to say that we were far, by that point, better prepared to successfully manage the patients with COVID along with keeping our practices. So I want to really, really, this is a tribute to all the teams, all the people that worked in the healthcare system. This is also a acknowledgement that we are here to serve our patients and that it's an honor to serve our patients because they have suffered immensely through this pandemic. So I want to thank Dr. Van Eggers and the Society of Critical Care Medicine for inviting me to present. And again, I apologize that we could not upload my presentation. Thank you so very much. Thank you so much, Dr. Ochoa. So through all the presentations, we have something in common. I think we are talking about different places, different states. We practice in different states, but in general, we go through the same challenges. And I think that we hear how to solve these challenges are similar. Sometimes it's like adaptation, it's flexibility, it's innovation, right? It's like how we are going to come and solve problems. I think like most of us have some training on leadership and how to adapt and how to move, but putting it through a real life problem at the size of the COVID-19 pandemic, I know has been very, very, very difficult. But it's also true that through crisis, I think it's when the best of our leadership comes out. And we always say that we can recognize the good leaders through how they respond to crisis. When you are a leader and you don't have crisis through your career, then likely you're going to pass more like unknown. Nobody's going to maybe remember you if you don't have that opportunity. So we, as critical care society, we learn how to take the best from the worst. So very happy to start the QA sessions. So I'm going to start reading some of the questions that we have in the chat. And I think this really will go for Dr. Herlihy. How do you maintain a positive rapport with the command center and frontline staff? How did you incorporate suggestions and new ideas from the frontline nurses? We struggle as more patients require more nurses who were pulled into the COVID unit and were less comfortable. The core team was good, but found it stressful to have additional burden of supporting nurses who were pulled in during our second wave in December. And thank you for the question. Yeah, great, great question. So one of the things that at least I learned, I think early in the pandemic is that to lead from the front rather from the rear, depending on where you are in the organization, but as the leader of our critical care group, I needed to be out in the wards and working in the wards for two reasons. One is to see the problems firsthand. And two is to support the frontline workers. But over the years, and I've been in this business for a long time, over the years, I've really learned that as a leader, it's very, very helpful to develop the skill of identifying problems or framing problems. And I've really learned to listen to the ground troops. I mean, the nurses were very key to developing solutions to very practical problems. Where do we put the ventilator monitors? How do we decrease traffic in and out of the room? The nurses were the first folks that were telling me about line clotting, those kinds of things. So I've learned to take that input, construct it and to push it in ways that are understandable to senior leadership and command center type people. So in our organization, like most organizations, we have a disaster response model that has a command leadership, but it's also my experience that many people at that level need to hear from the frontline troops. And I think I learned to translate from those frontline troops into language that command center could understand into actionable items, equipment, protocols, drugs, et cetera. So very, very good question. But again, I would say in brief, for me at my position, sort of in the middle, middle management, critical care leader, being out there working in the units, seeing the problems firsthand, the work staff is very innovative. They can help us to find solutions. And of course, I am fairly imaginative myself. I would participate in that, but really most of the solutions on the ground and even many of the problems were quickly identified by the work staff. And my job was to frame them in such a way that the leadership could understand them and act on them. That's very good. I think critical care teams are used to adjust and respond, but what you mentioned, leading from the front, I like that phrase. And I've been able to communicate with the teams. I think when the nurses have a lot of fears, if you address the fears, then it makes the job easy for everybody. I have another question from Dr. Elmett. I'm so sorry, they're moving here. For Dr. Webster. They continue popping up the questions and then disappears. But she was asking about how were you able to dedicate an APP team for lines and procedures during evenings and weekends? It's not easy from a staffing perspective. And I agree with that. It's just when everybody's getting tired of the long hours of work and everybody has needs in the floors, in the ICU, in the different ICU lines. So Dr. Webster, how were you able to do that? We had to stand it up in just a few days. We noticed that the collapse rates were going up because of patients, their lines had difficulty changing these lines in a very fast and expeditious way. So we basically did this by committee. Everybody signed on, everybody contributed their time, put in extra time. And it did actually added some variability to our jobs. We went from bedside providers to actually applying and putting these lines in at a very high rate with a high level percentage of completion at the bedside. But it took a lot of more of people just giving their time and just putting their efforts forward to make it happen. We had some key members of our group that actually headed this team. And then we had to put a communication basis in so that people can adequately give us information instead of putting it into the computer and asking for lines, they could tell us more about the patients and what the expectations were for the application of these procedures throughout the critical care service. And we just continued to do that. And we were doing quite a few lines, changing them out, getting the collapse rates under control. And like I said, a very, very high level of efficiency and success at the bedside throughout all the critical care areas throughout the hospital. Thank you for sharing your experience about that. Because I think, again, everybody has faced those difficulties and hearing about solutions is very important. I think I have another question for Dr. Herlihy from Dr. Ahmed, is how can we normalize the health and wellness of our teams? Some groups are developing psychological first aid groups, peer support groups, or checking by a psychologist with an opt-out option. What investment should system provide to both normalize and fund the mental wellness care necessary as we continue with surges for the foreseeable future? And I'm asking Dr. Herlihy, but I know that Dr. Webster also can give us some input from his PhD in psychologist. Yeah, I think that's another great question. And I'm not sure I completely cracked the code, but this is what I'll say. Again, there's a lot of value in leading from the front. When the troops see that you're in the trenches with them, that helps a great deal, but it also informs you of what the feel is in the different units. If you have those relationships, the providers will tell you what they're feeling, where they're at on the emotional spectrum, energy spectrum, how this is affecting their lives. So I think leading from the front and listening is the start. I think, number two, that physical exhaustion, emotional exhaustion simply needs, in part at least, rest. We have to have systems and tools to identify when people are at that emotional and physical exhaustion point. There are actually some tools, some survey tools that can help with that, but in times like a COVID or a pandemic that are moving very fast, again, being out there talking to folks, listening to them, observing them, I found to be very helpful in terms of rapidly assessing this state of emotional and physical and energy, health of our providers. And a third thing I think I learned is great, great strength is from the team, right? So the relationships of the team members to each other, to their director, to their nursing director, to their physician director, and to various levels of the organization, and actually to the community. I mean, the relationship of the care team to the community is a powerful, powerful tool, I think, to help. Folks get burned out emotionally. Folks get tired physically. But I think this deep into a pandemic, it's inefficacy. You get these patients. By this time, we all know there's a group of patients who are not gonna do well, and we feel so powerless. You know, that is really difficult emotionally. It's like facing strep throat before penicillin. You know, we just feel like we do not have the tool. But being part of a community, a larger community, larger than the unit, the section, the division, et cetera, being part of the lay community, connecting to the lay community, I think actually is very, very helpful. And we worked very hard at that. We worked through our media representatives to get our provider stories out there, to get our community to understand our struggle. And that really, really seemed to help us in terms of this feeling that, you know, we're fighting something that's very, very difficult, very, very stressful, et cetera. Thank you. Thank you so much. Again, we continue hearing our communication. I think that's what, it's just an advice for big crisis like this one, and even a small crisis in your personal life, in your personal relationships. Communication is a very important tool. I have two questions for Dr. Ochoa. The first one, I'm not sure if you treat pediatric patients, but let me ask this question. Did you take care of adults in pediatric ICU settings or bring pediatric providers to the adult ICUs? Do you have any comment? And I have a question about disparities for you. No, we protected the pediatric ICU and for the most part kept it separate. We did have the issue that the ICUs at the smaller hospitals not at the mothership hospital at Ochsner and Jefferson, which is the largest hospital, were getting filled and were having to ship patients. So we moved patients quite nimbly from place to place trying to best distribute the units. If I may put just a little comment on Dr. Webster's and Dr. Harless's answers on community. I think that the critical care physician, and it became very obvious during this pandemic, what an essential role we play at managing up to and helping guide the leadership of the hospitals and the organizations that are really understanding what is happening at the bedside. And so that idea that we have a foothold on the reality of the bedside, but can also go and communicate very fast to the leadership was very important. And the other one is what we call managing sideways, that is to our colleagues. So getting information not only around our colleagues within the institution, but the colleagues at other centers, again, Italy and Seattle and New York was very important. So that for me became a really obvious central, the essential role of us as critical care physicians. Thank you. Thank you so much. So I will, I will ask you also, Dr. Ochoa, because you were talking about when you are not necessarily appointed in the leadership position, but you have to step up and get to that situation. There is a question from Dr. Taylor, and it's, as leaders, did you have to make any hard choices during COVID about prioritization of treatment? Do you engage palliative care in any new way? What are your comments about that? Yeah, we did. But but remember, there was an institutional knowledge and again, a community knowledge and, and the community does play a huge role about Katrina. So what we did is before we even were really starting to run low on resources, we had engaged all the way up to the governor of the state at creating the roles and rules and what we were going to do if we were completely overrun, and we had to start triaging. Yes, we did adapt. And I think more than more than triaging we, which we did not do, we just adapted to a new way of doing things. So everything from taking the pumps out of the of the room, to minimizing contact to protecting us while we were doing intubations and procedures, we did adapt to that. And in that was listening to everybody listening to all the healthcare workers. But also understanding that we did have this organizational knowledge that we had learned from other disasters. And that was extremely helpful. Thank you so much. I have a question for Dr. Herlihy. So I know you're in the middle of a big enterprise. And again, decisions are complicated during these times. And we have some times to negotiate, we have to negotiate, but the short term and the long term objective. So how do you negotiate those objectives? Some people think that during the crisis, you maybe are staffing for the crisis, but the crisis is going to pass sooner or later. And then you need to keep your staff and your models for later for the long term objectives. So how do you negotiate short and long term objectives during the crisis? That is a fantastic, fantastic question. And, you know, I thought I'll give you a specific to talk around. So I found myself in the middle of a staffing crisis. So of course, when we were hit by wave three, so in our experience here in the south, I think it reflects the national experience, the data says that there's wave one, which was Washington and New York. That was March and April, that was much more severe there than here. But we really got hit in the summer in the south, right, June, July, August, a big wave. We were running here at the medical center, five ICUs, several floors and IMU. And then we're actually we're coming down off wave three. And it's really in wave three that that we're feeling the staffing stretched. So I found myself in the position of the administration wants to run parallel processes, they want to keep the business of taking care of our core patients going, which is hard to argue with, you need your valve, you need your transplant. But also, of course, we have this pandemic, which wasn't quite as severe as the summer, but it was pretty close. But the staff was really, really feeling stretched. So how do you talk to administration about this? And we started experiencing turnover, folks who felt the lure of the traveler dollar, folks who had experienced burnout and wanted a less stressful job. So at least the way I learned to talk to administration was this is not a two month problem. This is a five year problem. You know, we want to, we want to retain our core competencies, we want to retain our critical staff, we do not want to lose our institutional process memories, so that we need to invest now for the next five years in retaining these key elements. So that's, that's, that's the way I learned how to talk to my administration. That's a way I learned how to talk to the national administration is this was people I think, initially, we're thinking we just have to get through this. And then when you see wave after wave by wave three, it was quite clear to me that this was not a two month problem. And we needed to manage this so that we positioned ourselves for the next five years. That's how I learned how to talk to them. And that was language that resonated. Yes. And that actually resulted in action. I absolutely agree. Agree. Again, it's easy to focus in the problem in the today's situation, but then we're going to lose for the future. So thank you. Thank you so much for that, for sharing that personal experience for Dr. Webster. So let's bring again some of those difficulties. You're negotiating with administration, but then you have to overcome resistance. So from your perspective, when you overcome resistance within the organization, how do you face it? How do you negotiate? Again, for you, it's also how to negotiate with the staff, how to supply with the APPs, nurses, respiratory therapists, and the multidisciplinary team? Well, I find that in this situation, we had to have some very real conversations with people. We had to bond more, communicate more. The challenges were more demanding in terms of communicating more than we have ever communicated before. A lot of the things that we required, we had to step outside of the box to realize that this situation was going to require more than just our regular activities and our regular things that we do every day. When Dr. Hurley talked about the staffing, a lot of the patients we had issues, but some of our staffing also fit in the criteria of high risk. So we had patients, we had providers that were also at high risk. So we had to really have some real conversations with these people, reassurance, also look at each individual and place them in the area of their strengths. And having those real conversations helped us quite a bit. I think people realize that they can do more. And then we had to protect those providers, because if we lost providers, we would really lose control of what we were doing. So if we had turnover, whether people develop COVID, or whether whether our providers were sick, that was one of the biggest, my biggest concerns is how we would keep people motivated, and how we would keep people healthy. With some of these providers being in these high risk areas, we had some of our providers had their own health issues, some were pregnant, and all of these different types of things that we had to really, really, really keep that in mind. But having those real, real conversations with people was very helpful in keeping them engaged and keeping them working for the group. Yeah, thank you. I agree. I think that to be successful conversations with administration, again, that real conversation is necessary, right? It's like facing the reality. What are the fears? Let's face them. Let's look for the data. What is the impact for for the challenging situation and then go into what are the situation, the solutions we can we can propose. And I understand that sometimes as leaders, also, we have to just bypass the situation and try to make hard decisions. That's complicated. I have a question from Dr. Taylor for Dr. Ochoa. Did you find there was his hesitance to feed patients early because of their respiratory status? Did you see MDs that would formally feed early in the stomach, delaying feeds? Using this example, how to overcome fears of common practice when in unknown waters? Like feeding patients has been a very challenging situation. I know, I think still, we give patients very good data about our patients on BiPAP and high flow. They don't receive more than 50% of their nutritional requirements per day. And now we're keeping them three weeks on high flow. So what are your thoughts? I agree. I agree. I think a very, very rapidly evolving situation. I think the use of non-invasive ventilation provides highly significant challenges. There's now several publications, I have been a co-author in two of them trying to address these challenges. And so I'll urge you guys to try to look for those. We have no perfect solution for particularly for the non-intubated patients. I think that at some point, we have to deal with the issue that we are not meeting caloric goals. Now the question becomes, and that has been a real issue that has been discussed now and evaluated in other critical care populations for the last 10 years in multiple studies is, how important is it to meet caloric goals in the first seven days of the care of those patients? The problem is, as you said, is that these patients are now staying two or three weeks, five weeks, and we are getting, we're having a lot of trouble. We in the intubated patients, particularly because we have this very high degree of obesity, we are using hypocaloric, hyperproteic internal nutrition. And because we were not being able to supervise these patients very carefully, we minimized and modified and adapted very simple protocols. So essentially, we ended up trying to come down to a very simple regimen of nutrition, focusing more on protein, but a very huge challenge. We still don't have any data that tells us what we should be doing or not. Yeah, it's a it's a challenging situation. I personally think that that's what makes possible the end of the fight in the ICU when you have these frail elderly patients, three, four weeks on a high flow, BiPAP, Brexidex drips, they don't meet their nutritional requirements by three to four weeks, they are just offered, they just have no more reserve, and then they just give up and then the whole team gives up the family just like withdraw of care. So I think that we are making a long fight for a few weeks, and then the nutritional reserve just just puts the end of the fight. Agreed. So I have a question from Dr. Diaz Gomez. He first of all congratulates the team, great physicians and APP's leader. Thank you for leading this extraordinary session. Would you please share your plan on possible yearly drills in our ICUs regarding pandemic preparedness? If so, which are your preliminary plans? And if any of you want, or maybe Dr. Haley, he would like to comment about that. Before I would like to say that we have been training in preparedness in disaster preparedness and emergency preparedness for years. And I think many programs have like a yearly plan for drills and conferences and talks. But I think this pandemic show us that the need is higher than that. I think, like, at least in my institution, we have at least three conference about emergency preparedness during the 2020, because we just have to adapt and change so quick, so frequent. So this is an important comment, we have to escalate, we have to step up our preparedness. And I agree that simulation is the best way to do it is just simulation at different levels, right? It's not only going to the same center and having manikins and models, we have to do tabletop training, we can do like, everything is in Zoom right now, like videos conference, we have a lot of training for this pandemic on videos, where we just have opinions and like a range of ideas. So Dr. Herlihy? Yeah, first of all, thank you, Jose. And I think that's maybe more a suggestion than a question. But I love, I love, I love the question. So there's different levels, I think of the question. So yeah, I think that the society is particularly positioned and is developing and has developed packet learning packages that can can serve as a platform and framework to do drills. And, and, and I agree that that simulation is absolutely the way to go. I think that the society can play a great part in setting the platform for what a simulation should look like. And I think, you know, what's the cadence of a simulation is a good is a good question. Now, I spent some time in the military. So once a year, we actually had a mass casualty simulation. And in the military, if used, if you look at the military in general, the course of war games, etc. So simulation is, is, is a great idea. I think the society is positioned to develop a platform for that. But I will also say that, I think, at least one of the things I have been thinking during the pandemic, is that in our training systems, for critical care, we do not have some things that maybe will set us up better for success in an unexpected, rapidly evolving emergent situation like a pandemic. So in our training programs, do we have systems management training? Do we have team management training? Do we have training to manage personnel, every critical care doctor, at any level is a team manager, right? And as a system manager, even if you're going on rounds daily, as an assistant professor, as a community doc, with your bedside nurse, your director, your nutritionist, your team manager, your systems manager. So I think at least one of the thoughts I've had during the pandemic is we should, as a society, maybe work harder, make more available, develop better platforms so that we can do these drills and simulation is absolutely the way to go. And number two is maybe we should think a little bit more about our training systems whereby we can train our people to quickly fill roles in leadership in unexpected crises that require these skill sets. So those are two thoughts I have. I'd be interested to hear the other panelists' thoughts. I know Dr. Ochoa, Dr. Webster, would you like to make a comment about the simulation training? Just to echo what Dr. Hurley has said, I do have a little bit of a 30,000 foot comment, which is, if there's a silver lining to all this pandemic is how critical care has been, as a specialty, been able to project itself outside of the ICU. And how people have realized how important the role of critical care is. At an institutional level, the ICUs have been able to now demonstrate its central role. And everybody has now learned, particularly at a leadership level within our healthcare systems, what we do, and why we are so important. And they have learned to listen to us. And I think that that is a huge change, but also at a community level. I mean, I am amazed now that I listen to the radio, and I listen to other lay people's discussions, and that critical care now has become a part of the community, and that people now understand that there's ventilators, and that there are, I mean, what really is an ICU. And I think that we should, as a society, continue to provide that leadership, use this, again, as a silver lining, as a platform to continue to grow and really participate in far bigger issues, more than just our world in the intensive care unit. I think I kind of agree as well. I think that having the simulations are very good. But I think in this pandemic, it has exposed us as providers, and it has demonstrated our levels of weaknesses and strengths, and flaws in how we do our daily business, and things that we need to improve, and making us more efficient as a team and as individuals. So I think the pandemic, for me, it looked at how we need to improve communication at the bedside, to families, to nursing, and to all of our partners in this together. And we realize now, I think that what I have seen, especially with the families, that it has been a tremendously difficult situation for families being away, and the patients not getting the support, having innovative ways to do that, and really focusing on things that will help abridge those problems. And I think that, as we were, a lot of institutions have done very well, but I think that we have been very exposed in terms of our weaknesses, and how we handle those things in the past, and what we need to do forward. So I think those are the things that I've learned from it. I do think the drills are good. And I do think that, but it's nothing more revealing than a real life situation, especially a pandemic. Yeah, it's true. Real life is absolutely harder than what we can create as a scenario. But we do need the simulation to be prepared for it. For me, for example, at the beginning of the pandemic, just to have that opportunity, even before we have the real patients in our hospital, having the opportunity to simulate and rehearse with the residents, with the nurses, it decreases the fear so much, because at the beginning, everybody was concerned, how am I to take care of this patient? How am I to be protected? So that will bring me to another question from Sandra Hanman. And it's a very interesting question. I'm going to guide it to Dr. Webster. So I think we have talked a lot about what are the difficulties for the staff in general, what is the burnout for the staff, right? We have talking, we have been talking about staff has to work for long hours, we have to carry this PPE that is uncomfortable for us for long hours, we have been working in this stressful environment, where we are worried about getting sick ourselves or bringing sickness to our family. And we have talked about that. But the question is, how did or do the team leaders maintain their sanity? So what is your experience about the leaders having their decreasing their stress, decreasing their burnout, to continue being our leaders during the crisis, we need sane, we need healthy leaders to give healthy teams? Yeah, I think that's that's a great question. And in a difficult question, because you know, as leaders, sometimes we don't think about ourselves, we we put ourselves out there in harm's way. I think that we really have to look out for one another. And and as a team, because we need to recognize when people because most of us are, I would say type A personalities, I would say, we go getters, we put ourselves first, we're going to work the hours when nobody else can do it, we'll step up and we'll take it, we'll do it. But we also have to listen to our team, and have to communicate with our team. And those people have to, I think, have been effective in stepping in, and keeping us aligned where we need to be. I don't know if it's a great solution. I don't think that I can say it's a great solution for doing that. It's definitely a team, it's a team, it's a team effort, for sure. I don't think individually, you know, the people that work for me and myself, I have to watch out for them. And I have to recognize when they're in a situation or when they're having problems, that I have to have again, those real conversations, hey, are you tired? What's going on? How are you feeling? What can we do moving the staff around moving and doing things, but you also have to have a group of people who are dedicated to doing that. And in this situation, we had a very strong team, and people more than will more than willing stepped up and stepped up and took roles, but also recognize when other people were at a breaking point. At one time we had about nine, I guess we had about nine providers within the course of like a week that actually were getting sick and were exposed to COVID. Given all the things that we were doing and all the mask and doing everything else, it still happened. And we really had to had to step up. And the next person had to step up, but we really had to look at each other and support each other collectively to get through this. Yes, thank you. I also think that this has been a particular crisis, right? I think we have faced crisis like the economical crisis or the small pandemics. But COVID has special characteristics, it has brought to us the attention to our personal lives, right? So we're not counting houses, everybody's meeting on FaceTime or Zoom meetings. Everybody's isolated from the world, but insulated in your house. So I think it has put an extra care in your personal life. Like how are you dealing with your, how do you cope with your situations, right? Many times we were coping with like, traveling, going to conferences, going out with friends, and that's cut. So I think the crisis has brought that question of how you're coping with your personal issues. And then from that point of view, for leaders, that's important to focus in their personal lives also, in their families, in spending time with themselves, with their families and with their loved ones. So I well, also also bringing strength on their faith or in their, you know, yoga, relaxation, you know, reading books, everybody has, during the crisis had to like bring something from inside to keep their sanity. So I have a question for Dr. Ochoa. Carla, can I just make one quick comment about that. And that is, in regards to that question, of course, you need to, as leaders, we need to stay attuned to our physical exhaustion point or emotional exhaustion point. One of the things that I think has happened to me during this crisis is that I've really learned to draw strengths from the workforce. So all of us as leaders report up. We have to report our CLABSI rates and our mortality index, and we are responsible for finances. And so we're always reporting up. And so, at least in my career, I felt a lot of pressure from those metrics and reporting up the people who pay my salary. But really, during the pandemic, I've really drawn my strength from what I've been able to do on the ground for the workers and those relationships. I mean, it's, in a sense, flipped. They are, to me, they've become my primary responsibility. They've become the people to whom I owe the deliverables, even more so than my bosses. And as paradoxical as it is, that seems to give me more strength, having them as my North Star. So that's how, that's one of the things that's changed me during this pandemic, I think. Thank you for sharing that, because it's true, it's true. I think we have changed through the pandemic and refocused about a lot of goals and insight. Dr. Ochoa, I would like to ask you, because you are in the area of Luciana, and I think you can give us your opinion about the vulnerable people, the disparities. So as Dr. Webster was mentioning, this pandemic have shown our weakness. And we know, through the country, how the vulnerable people have been affected in a disproportionate way, right? We talk about people with low income. We talk about people, disparities on race. And we talk about disparities on the sentence, like the language that you speak, the access of healthcare. So what is your opinion about that situation? And the question really will be, do you think that the changes that we have been implementing or that we implemented already are enough, are good? Are they going to help us to do better in the future? We are still in the middle of the pandemic. The pandemic is not over, and we need to have good solutions for how to move forward. So I think that the very early realization that we were seeing a disproportionate negative effect of this pandemic on different groups and minorities became for us a really important issue. I think that at an individual level, acknowledging this and trying to do our best at understanding this and understanding that there are cultural differences and that there are individual decisions that we need to make for the care of different patients is important. But I also think that it exposes, as Dr. Webster said, this weakness in the healthcare system and in our systems overall. I mentioned the issue of obesity. Obesity is interestingly an economic class disease so that obesity is highly prevalent in minorities and people with lower incomes compared to higher income or higher education groups where obesity is still of limited incidence and prevalence. And so I do think that as leaders, not only within our healthcare and our people in the daily trenches, we have an obligation to make sure that we acknowledge this and try to do our best, but also as leaders, as we project outside, we have to understand that this pandemic has exposed severe weaknesses in our healthcare system that need to be addressed. Thank you. Thank you so much. I think we still have 20 more minutes, but I would like to start making some questions about the future, again, while we're still in the middle of the pandemic. So we have a question from Beth Taylor. Let me ask it to Dr. Herlicki. The cause of the pandemic to healthcare system was high leading to four loads, surgery cancellations, et cetera. For the latest surge, the system seems to have a better idea on how to reposition the staff to work in new ways. Will this discussion continue moving forward to prepare for future disasters to protect employee likelihood and limit impact on healthcare system overhead? Yeah, I think the short answer is yes. You know, I have seen, just as I have changed during the pandemic, I have also seen senior leaders change in the pandemic. And the fundamental change is many of the workforce values that they took for granted, well, they don't take for granted anymore. And I think that's the beginning of having more... We always talk about patient-centric health, but when you're managing an organization, that's the beginning of a more employee-centric system. Better consideration for the health, well-being, sustainability of our workforce begins with recognizing their value and rethinking ways that we can allow them a path to progress in their career, ways that we can allow them to better integrate into their personal lives, ways that they can draw more satisfaction as team members. So I think what I have seen in the pandemic from my hospital to the 17 hospitals system that I'm actually in to the national is a recognition at all these leadership levels of the value. You don't really think of the value of respiratory therapists until, oh my God, everybody's on a ventilator. You don't think of the value of the high-skill ICU nurse until they may not be there. So it begins with that understanding. And when you have that understanding, solutions really come from listening to that workforce. And that's what I have seen. I have experienced that, but I've also seen it in senior leadership. So I think the journey really is just beginning. And to be honest with you, I'm very excited about it. I'm very excited for the potential, ultimately, to care better for patients. Because if you have more functional teams, you'll do a better, critical care is a team sport. If you have more functional teams, you'll do a better job for the end user, the patient. Thank you. Thank you so much for that answer. I will have a question from Dr. Diaz Gomez for speakers and moderator. And I think Dr. Herlihy already make a comment about that. So I would like to start now with Dr. Webster. It was asking, what makes you feel that you are a better leader after the pandemic? If so, how do you envision mentoring others in this regard? I'll also rephrase the question also to, during this crisis, what do you think is your biggest achievement? What did you achieve during this crisis? And then you will carry it with you to the future and use it to mentoring others in the future. One of the big things is the educational experience through it all. We were able to learn more and to share that knowledge with others within the group. We, during this situation, we grew as providers, tremendously grew as providers. I think some of the people that maybe didn't have certain skills or was limited in skills, they stepped out and they developed those skills. The other second thing that I think that we will carry forward is our level of communication. Level of communication at the bedside, level of communication to the administrative level, as Dr. Hurley, he had stated. Everyone has changed, including administration. They've been able to see things quite differently. And we have certainly in these situations have demonstrated our value. And so a lot of people are looking at people that maybe previously they didn't see before. And so those are the two biggest things that I think that we move forward, is ability to educate, to effectively educate, and also to communicate and effectively communicate. It has to be there. You have to have a team concept, as Dr. Hurley, he had alluded to. It's a team sport. And the tighter the team, the better the team, the more effective we are at the bedside. Without a team concept, one person can't do it by themselves. But as a team, we can do much more and go and demonstrate much higher levels of efficiency when we work as a team. So those are the two things that I think that we will continue to build on those things. Thank you so much, Dr. Ochoa, Dr. Hurley. Yeah, I do have some comments. I think that for me, one of the biggest lessons is learning from our mistakes and trying to be very, very efficient at understanding when we are doing things wrong. And that includes everything from our daily clinical practice to our leadership skills. So for example, in our case, a group of specialties, including surgery, felt a little bit disoriented, particularly in the initial onslaught, where they were like, okay, now we closed the operating room so what am I going to do and how can I help? And I think one of the mistakes, at least at a personal level, was not to really support them more and bring the surgeons more, because I was the person, or at least I was in a privileged position where I could go between critical care and medical ICU type of care to our surgical team. So learning from that was a big one in doing that. I also think that there was a huge lesson in really putting the word to translating research. I think that we have, or at least during my career, we have all paid a little bit of lip service of translation. We know that it's incredibly inefficient, that it takes 17 years on average for us to translate something from the lab to the bedside. And now we are saying we have to do this in less than a year. And so if I have to say we are, and I've been very privileged of participating in some of this, we are moving a lot faster into translation. And so a huge lesson for all of us. Thank you so much. Yeah, you know, one of the very interesting, I mean, gosh, you've all had so many interesting experiences, but I think a very interesting and transformative experience for me is I spent most of my life in an academic medical center. And we are so privileged in an academic medical center to have all the resources that we have, but so much of the care, and I don't know what the numbers are, but so much of the care in our system. So again, we're the hub of a 17 hospital system. The Texas Division of Common Spirit. Common Spirit is the largest nonprofit system in the US, 150 hospitals. And most of those hospitals are community hospitals. And so I really got to know what the struggle, or at least I got much more familiar with the struggle of the community hospital. Oftentimes where the rubber hits the road for many of our patients, they go to their community hospital. And so how do we help and support those community hospitals? I learned a lot about EICU. I learned a lot about the ability of electronic hubs of expertise, a little bit beyond the concept of EICU, the EICU consult, if you will. I learned about, well, how can you leverage the resources that are at some of these community hospitals? Who can put in lines? Who can do the intubations? Who can be the ground troops, the hospitalists? Who can, and how can we manage at night? So to me, that was a real revelation. Again, I think the society, many of the leaders and a lot of the leadership of the society is academically based, but a lot of the work of critical care is in community hospitals. And really one of the things I realized is we need to think a lot about how we can leverage our academic medical centers, our hubs, our expertise to help these folks on the ground in their communities to deliver best care and best practice. And I think there are tools out there and I think there are ways to do that. There are ways to communicate. There are ways to evaluate. There are ways to support these providers out in the community to scale our expertise as providers in critical care. Absolutely, I agree. Very, very important comments because yes, we in the academic centers, we only carry 30, 40% of the ICU patients in the country and no way we're going to carry all the COVID patients who are critically ill. So that's very important how to expand. And then we can put again that in communication in simulation, in training, in education. Yeah, so for me, also there are some important points. One, as you mentioned is team. Who is your team? And you say how we are a multidisciplinary team. What is one of the nicest part of the critical care society? How multidisciplinary we are. And then the crisis has been extra value to everybody. The nurses, the APP, the respiratory therapist, the physicians. Now the people who cleans the rooms, the people like technology who makes our Zoom meetings with the family members, with the palliative care team, how we innovate to provide services in the way that we know how to provide it. But other part also is to remind us that we are the lucky ones during this pandemic, right? We are the people who still have a job. Not like many other people in the country who are thinking what I'm going to do or I'm at home without a stable income. I think we're the lucky ones who can also provide a service during this pandemic to the country and to the world, right? So through our work, we are sustaining the situation and we are letting the situation to go to sustain until we have solutions, real solutions. So I think that the crisis, the pandemic has remind us how valuable is our work. And from me personally, I would like to thank everybody in the society, every of the members of the critical care society, the critical care work for all their work, all the work that they do during this pandemic. And I know for personal experience, for my teammates, and I'm sure through experience around the world, how many times we have to put ourselves in our needs in front of, we have to postpone them to support the needs of our patients and our hospital. So I think those are learnings from this crisis. So we have another question. I think that Dr. Lely will be good for you to give us your opinion from the lean. Say, now that our patients numbers are starting to go down and we have regular patients filling beds, we have also seen an exodus of nurses leaving for lucrative travel assignments financially. Any advice on how to wrap up with the team when it's not the patient volume expanding, but nurse volume decreasing? You know, that is a fantastic question. And it's a question I ask myself often. So I certainly have spent a lot of time engaging, as I was saying earlier, something like the middle manager. You know, I am pushing to my executives what I'm hearing on the ground, but I also bring them data. You know, here's the turnaround in this unit, I'm sorry, here's a turnover in this unit, here's a turnover in this unit, here's a turnover in this unit. Here's the critical skills we've lost. This is a percentage of nurses who can do VAD care, et cetera. So I push to them the value of our current practitioners and what that essentially translates into in their world is incentive bonuses, retention bonuses, better packages to help develop a career, educational bonuses, escalation in the latter pathways that are better developed. The steps are easier, et cetera. I'm very interested, I'll have to say, I'm very, very interested to see what happens once we come down to maybe something like a steady state eventually. You know, this pandemic has come in surges. So we have surges and it's especially this third surge, at least here in Houston, that we've seen really the turnover and the call of the traveler dollar. And we've lost a lot of our really bulwarks, pillars of our nursing, especially, but also respiratory therapy, et cetera. It's really gonna be interesting to see what happens when we reach something like a steady state where, you know, for the next two to four years, we're gonna have maybe one ICU, one IMU. Hopefully, it's a little hard to tell, obviously, with the variants out there, but what will it look like in terms of these travelers? Will they come back home? What will happen? Or how do we get them back in the fold? How do we restructure them, get them back to where they're members of the team? That's gonna be very interesting. I don't know what that's gonna look like. I think a lot about what that's gonna look like. So I'd love to hear from some of the other panelists, but I'm not sure. I do know that my institution, my executives have heard the data. They've heard the stories and probably the most effective thing I did was put them on rounds with me, walk them through the units and let them hear from the workforce exactly what they're experiencing. And that really translated into action. And a lot of the action was dollars, but it was thoughtful. It was structured in a thoughtful way to retain them, to grow them, to build them. You know, people aren't just interested in the dollars. They wanna be part of a team. They wanna grow, et cetera. Thank you so much. We have a little less than four minutes. I don't know if there is any other opinion. Otherwise, I have maybe one or two more questions for closing. I would like to ask a question to Dr. Ochoa you were talking about. Or the question is, what would be your advice, your personal advice for the clinicians who are not in a leadership position, but they want to help up. They want to step up, but they are not part of the group that makes the decisions. So what would be your advice for that? If you look at it, I managed a surgical ICU. So I could have really said, this has nothing to do with me. And I mean, I'll take care of the patients, but I'll just play a clinician role. The question was for me, is it more important for me to step up and try to participate? And so the absolute truth is that I had no job description for me. All I said is I went to the leadership and I said, things are going to get tough. Our medical colleagues who really, I mean, are the leaders in this, were already stepping up. I helped them in that process. And I started to get prepared and try to get prepared my unit to what is going to come. And so in the same way, the truth is we all as physicians have this huge leadership role, but we have not been taught how to provide leadership. That's not part of our medical school. And as Dr. Webster really said, and Dr. Hurley really said, the lesson, the big lesson is we are here to coordinate a team. We cannot do this on our own. We are really here to coordinate a team. Now, I want to make sure that it's not only the team at the bedside, which is essential, because that brings us the meaning, brings us the existential meaning for what we do. But it is also our role to project ourselves and say, okay, guys, we need to manage up. We need to manage outside of our little daily team as we protect our daily team, as we understand the big picture and we project ourselves. But I think it is a matter both of personal commitment and my hope is that we as a society, as a society of critical care and as a medical society start learning that we need to sit there and educate ourselves in leadership. You said something very, very quickly on the importance of meaning, of existential meaning. If you look at that, at existential meaning that moves mountains far more, far more than economic incentives or other things, the recognition at the bedside that you are doing a good job, the empowerment of your nurses, of everybody is from my point of view, a fundamental skill that you have to develop as a physician. So I hope that helps. Thank you so much. Thank you so much. And I think we just have like less than a minute. So I want to thank everyone, all the speakers for sharing your experience. They have been extreme value for me and I hope for all the participants. Thank you for all the participants who join us. Remember that the conferences are going to be available in record in 72 hours. And I think for the next 24 hours, we can answer some questions online. And I would like to bring what is purpose, as you said. I think I was thinking, what is going to keep us engaged? Like we're getting born out. We have an idea working in these conditions and the crisis is not going to be over anytime soon. So how do we keep going with motivation, with quality? And I think, again, go back to our purpose. We like to save life. We like to work for people. We like to make the world better. We like to make our ICU a better world for us, for our colleagues, for our teammates, for our patients. So I think that when we connect to that purpose, that will give us the food to continue until the crisis is over. So again, thank you so much. Thank you to the Critical Care Society for give us the opportunity to talk about this important topic and continue enjoying the conference. Dr. Venegas, great job. Thank you so much. Thank you.

panel discussion

experiences

challenges

leaders

healthcare

COVID-19 pandemic

teamwork

communication

supporting staff

simulation training

disparities in healthcare

learning

improve healthcare systems

mentoring

leadership skills