The COVID-19 surge, in particular the first big surge in New York City, really underscored how well pediatric and adult teams can work together, even in an adult emergency. My name is Mark Nunley. I'm the Director of Adult Critical Care Services at NYU Langone Health, and I'm happy to talk to you about our experiences today. I have no disclosures to make. We'll talk about the impact of the COVID-19 surge, challenges and benefits, and you'll hear about future opportunities from myself and my colleagues on this panel. To set the stage, in March 5th we had our first COVID-19 adult patient admitted to NYU Langone Health, and we'd rapidly tried to spool up, but found ourselves quickly having to respond to large volumes of patients. New York City was a surreal place at the time. Normally crowded areas were completely depopulated, but in the hospital we saw completely the opposite. There were patients everywhere. Our response to the surge was to spool up as quickly as possible using the principle of logistics. As a review, logistics is about detailed coordination between people, facilities, and supplies. That's the people that provide the care, places for them to provide the care, and the things they need to do it effectively. And this is where our pediatric colleagues provided ample amounts of all three in order to help us sustain what ended up being a large but not overwhelming surge. In terms of personnel, we built something called the COVID Army, which was to repurpose clinicians as many ways as possible, and into this breach is where our pediatric team stepped up. They helped staff different units, and in the end they staffed COVID-dedicated adult units as well. In our pediatric residency, the clinics were minimally staffed at this point in time. There was a reliance on telemedicine. A lot of elective rotations became virtual, but the most important thing was many of the residents, and a chief resident inclusive, volunteered to work in the adult COVID units, and they were deployed to our medical ICUs and medicine floors. Our pediatric resident heroes were even shown on the signage and the sidewalks of New York. True heroes indeed. Our congenital cardiovascular care unit, the CCBCU, eventually became a full-thickness adult ICU, and this was done by first keeping the critical teams together, so teamwork still mattered, but supplementing with adult expertise, including a pharmacist, a MECU fellow in attending, that supported two different surge ICUs. They did keep five beds for congenital cardiac patients, and these were kept separate from the COVID patients through pressure walls, and specialty teams for patient procedures also helped maintain patient care. In terms of supply, the most important things to point out was we had rapid consumption of our PPE, over 20 fold at the peak. We had simultaneous allocation by our supply chain because our primary vendors could not keep up, and we needed to stockpile in order to stay ahead. I mentioned reuse of PPE, which was vital during our peak consumption. We achieved this by issuing PPE on a regular rolling basis to our staff, and expected them to hold on to it and use it until they got their next product, or if it wore out. Other adaptations in our units included stockpiling material, as you see on the left, and writing critical information on the doors. Our pediatric ICU was a good example of adaptation, and our teams rose to the challenge of caring for adult patients, in this case up to the age of 32. This pediatric unit became more of an effective step down, managing patients that were not quite critical, but were still transitioning to an acute level of care, and it helped us maintain our throughput. The success of this unit was predicated on adaptations, like you see with the infusion pumps outside the door here, and rapid education and dissemination of protocols and training. This dissemination was highly successful, and in this case, information on things like adult resuscitation and adult drug dosing could be distributed in real time and updated as necessary. Our cardiovascular congenital care unit converted to a full thickness ICU on April 1st, about a week before we saw our peak surge, and this was one of the innovations that allowed us to bend and not break. In preparation, the teams went through a crash course in adult critical care, taking advantage of some of our excellent senior clinicians in our simulation center, and all the protocols and policies were circulated before the first patient rolled in. The CCBCU, in the end, cared for a peak of 15 patients. They were anywhere from 30 to 73 years of age, and this is in a unit that previously had an overwhelming majority of patients under one year of age. Of course, almost all of them were intubated. One patient was actually managed on ECMO, and the outcomes in this unit were the same as in our adult units. Our pediatric colleagues did a spectacular job taking care of patients in a very difficult time. Our neonatal intensive care unit continued its regular operations because we had a fair number of deliveries, in particular to COVID-positive mothers. We were able to spool up testing for the neonates. One thing that did change dramatically was that our OB discharge policies allowed us to move mothers out in about half the time they did before COVID. One area where the neonatal ICU was different was in our visitor policy. We severely restricted visitation to most of the adult units, only really for the end of life, but in the neonatal ICU we still allowed two visitors, one at any time. We did make ample use of telecommunications like we did throughout the hospital to connect families with patients, and the book of business in the neonatal ICU remained high. Through the height of the COVID surge, a real human side emerged. This sustained our clinicians through the most difficult of times, and we saw information like you see here, personal information about patients, to make the whole experience a little bit more human. Something really important that we learned from our pediatric colleagues was the value of color and art. Crayons and chalk sustained our clinicians during the most difficult times, and really the pediatric experience was extrapolated to the ICUs all over the hospital. Outpourings of gratitude extended outside the hospital as well, including the evening clap-off where the fire department or police department would come and salute the health care workers. At the height of our surge, it really was all COVID all the time. A few innovations that helped sustain our operations when we had such a large influx of patients included an airway, venous access, and prone positioning team run by the Department of Anesthesiology. We also made good tactical use of ECMO. During our first surge, we put 30 patients on circuits and enjoyed a 90% survival to hospital discharge. Our longest run was 153 days, and importantly, we always kept an ECMO circuit available for meconium aspiration, realizing that pediatric patients would have need as well. Now I mentioned that we bent, but we did not break, and to illustrate that, I want to show a schematic of how the COVID patients came through our hospital. Here you see our hospital system. Circled here is our new hospital pavilion, which was opened about 16 months prior to the first COVID patient arriving. It was designed to be an adjunct to our original hospital shown here, the two shared facilities, and both cared for COVID patients throughout the pandemic, in particular in this first surge. This is a schematic showing the two floors, the old hospitals on the left, the new hospitals on the right. These are not to scale, but you can see where the different clinical units are, and as I send this through a time phase, you will see COVID come through as a maroon, taking over all the different ICUs, and in a bit, you will see an arrow pointing out the pediatric units, which were so important at the peak of the surge. You see a fair amount of influx, and there are pediatric units opening up to help decompress. The surge continued. We began to open up new facilities in our orthopedic hospital, and in some of our other inpatient capable floors. With time, the surge began to recede, but even by the middle of April, we still had a large number of COVID patients, including in our pediatric units. Finally, by the middle of June, we are able to move back to mostly normal operations, but with still a modest COVID footprint. At times during the first wave, it seemed like all we could do was react, but in reality, we did very, very well, and we were able to adapt in real time. My colleagues shared several interesting anecdotes from the pediatric experience during COVID. The first was learning to use phenylephrine as a presser, not common in the pediatric world, but certainly in the adult world, especially with atrial fibrillation, which again was an uncommon arrhythmia for pediatric operations. Many of our COVID patients suffered strokes, and our pediatrics teams developed expertise quickly, working in tandem with our neurointensivists. One of my colleagues told me a story of an elderly woman with immaculate red fingernails. When she asked her about them, she said, I did my nails as soon as I knew I was coming to the hospital because I didn't want anybody to think I was a frail old woman that was going to die. Particularly touching were the evening clapouts. Here's a picture from the pediatric ICU looking out at the fire department saluting our clinicians. Our congenital cardiovascular ICU did a survey after the first wave to see how confident their practitioners were in caring for adult patients and whether they'd be ready to do it again. The results were impressively positive. 100% of respondents reported the same or improved confidence, and 75% reported improved confidence, and as you can see, an overwhelming majority were fairly or very confident in caring for COVID patients in the CCVCU conversion. Importantly, the respondents also preferred to maintain their care team, something that was probably essential to the success of that unit. The conclusions I'd like to leave you with today is first that pediatric intensive care is intensive care, which is about adaptability, and pediatric intensivists are as capable of caring for adult patients as anyone. Learning went both ways between the pediatric and adult community, and I think that kind of cross-pollination is great. Keeping the teams together was most helpful in the pediatric ICUs and led to efficiencies and good outcomes. At the height of the surge, fundamentals really did matter. In the case of learning about pediatrics, it included dosing and resuscitation. Expertise is a resource and it needs to be used wisely, and maintaining the teams allowed that to happen, and most importantly, we proved that we can bend and not break. We seem to be through the worst of it all, but there may be more to come, and we will certainly be ready. I'd like to extend a special thanks to the pediatric intensive care leadership, in particular Jack McKinstry, seen here on the right, for handing her anecdotes about how the units spooled up and sustained us. Most importantly, special gratitude for all the pediatric intensive care teams for what they did to help us get through the most difficult times.

COVID-19 pandemic

hospital collaboration

COVID Army

personal protective equipment (PPE)

pediatric and adult care