Good day, everyone. My name is Dr. Joy Howell. I am a professor of clinical pediatrics, vice chair for diversity in pediatrics, and assistant dean for diversity and student life at Weill Cornell Medicine in New York. Over the next few minutes, I hope to share with you a portion of our experience with redeployment as intensivists providing care to critically ill adults during the first wave of the COVID-19 pandemic in New York City. Specifically, I'll address our experiences collaborating with our adult ICU colleagues, including our orientation to adult critical care medicine, the centralized patient triage and bed management, as well as the processes and practices employed to execute education and information sharing at the unit, division, and institution level. First and foremost, good day, everyone. My name is Dr. Joy Howell. I am a professor of clinical pediatrics, vice chair for diversity in pediatrics, and assistant dean for diversity and student life at Weill Cornell Medicine in New York. Over the next few minutes, I hope to share with you a portion of our experience with redeployment as intensivists caring for critically ill adults during the first wave of the COVID-19 pandemic in New York City. Specifically, I'll address our experiences collaborating with our adult ICU colleagues, including our orientation to adult critical care medicine, the centralized process for patient triage and bed management, as well as the processes and practices employed to accomplish education and information sharing at the unit, division, and institution level. First and foremost, I must acknowledge that plans and in turn responses to the first wave of the pandemic were highly dynamic and iterative. Like many other institutions, we employed a supervised pyramid staffing model. At the apex of that model were adult critical care physicians who served in a consultant role overseeing both traditional and newly established ICUs. The first tier was populated by traditional ICUs, whereas the second tier assigned the ICU attending physician role to physicians with critical care capabilities. These included hospitalists, medical and surgical subspecialists, anesthesiologists, and ultimately, or eventually, pediatric intensivists. Flexibility was very much the word of the day in the spring of 2020. As the institution was preparing for the influx of patients, there were no specific plans to include the PICU physician staff in the surge planning. However, in short order, there was a dire need for more physicians, not just remotely capable but actually facile with complex ventilator management, vasoactive infusions, and management of multi-organ system failures. Thus, the institution leveraged the critical care capabilities of the pediatric intensivists. At the outset, it was unclear to us, as well as our adult colleagues, what the limits of our capabilities would be, and initially, a MICU attending and adult hospitalists were assigned to the PICU. This was short-lived. Similar to the physician pyramid staffing model, there was also a parallel nursing pyramid staffing model. Eventually, as the first wave evolved, critical care nurses, including our PICU nurses, were assigned to supervisory roles overseeing non-ICU nurses who were providing direct care to critically ill adults, both in traditional ICUs as well as newly established ICUs. In the week that preceded the reopening of the PICU as a COVID-19 pop-up ICU, our PICU nurses underwent largely experiential orientation to adult critical care medicine. They were actively engaged in care, including ventilator management, standardized, and by that I mean non-weight-based medication dosing, vasoactive administration, and MICU documentation. The goal was to replicate as much of the nursing care as possible in the PICU. Pictured here is the practice of bringing the ventilator screen and infusion pumps immediately outside of the patient's room in an effort to minimize staff exposure for simple tasks like dose changes of medicated infusion, as well as to preserve precious PPE. After the first two weeks as an adult COVID ICU, the MICU attendings were deemed more necessary on other units and thus were reallocated. Prior to their reallocation, we employed our typical model of dividing the patients into two teams. One team was staffed by a MICU attending with PICU fellows, residents, and PAs. The other team was staffed by a PICU attending with a MICU fellow and medicine residents. After the initial two weeks, the medical intensive care unit and adult hospitalists were reallocated and both teams came to be led by pediatric intensivists. With respect to ongoing critical care support, there was a MICU fellow assigned to the unit by day during the entire eight-week period that our unit served as a COVID ICU. Once the MICU attending and adult hospitalists were reallocated, we had ready access to the MICU attendings as our medical ICU is one floor away from the PICU, and the fellows knew how to reach the MICU attendings rapidly. In addition to individualized MICU attending consultations on an as-needed basis, care for common emergent conditions was standardized utilizing institution-wide teams. For example, for the few patients that were admitted to the PICU prior to intubation, upon progression to frank respiratory failure, an airway team populated by an anesthesiologist and an ICU nurse would come to the unit with their RSI medications, don their PPE, intubate the patient. Following intubation, the local intensivist, in our case a pediatric intensivist, would manage the transition to invasive mechanical ventilation. Similarly, to ensure efficient establishment of vascular access, there was a newly minted vascular access team that was staffed by vascular surgery attendings and fellows. The stroke team and the pulmonary embolist team predated the pandemic and functioned in a modified fashion throughout the first wave. There was briefly a period of time where there was an institution-wide set of proning teams, but very quickly it was realized that the need outstripped the capacity, and later on in-unit training was done to mount a unit-specific proning team. There was centralized patient triage and bed management during the first wave. Unit assignments, transfer requests, and unit-to-unit transfers were centrally managed by a bed czar that was one of the senior adult intensivists, as well as with the patient placement operation center and a specific cohort of nursing leaders. Communication and admission processes modeled the traditional practices in adult medicine. Unit assignment was based on patient acuity, the presence or absence of comorbidities, age, bed availability, goals of care, and the patient's code status. In an effort to deliver consistent and optimal care, given the circumstances, there were abundant resources, offerings, and opportunities for ICU staff to avail themselves of education. On the institutional level, there were daily 30- to 45-minute educational discussions on COVID-19-related ICU care and practice management guidelines. These were led by adult intensivists primarily and occasionally by adult infectious disease specialists. The topics of these afternoon sessions included ventilator management, fluid management, pronation, management of ischemic and hemorrhagic stroke, anticoagulation, and renal replacement therapy. In addition to the live discussions, there were also remote access asynchronous teaching conferences and journal clubs that were disseminated by secure electronic file sharing with daily email updates. And pictured here was the use of simulation training to mount up the unit-specific pronation team. And at the bottom, we have one of our respiratory therapy managers providing just-in-time training to the unit staff on use of the LTV ventilators. With respect to information and sharing and education at the divisional level, we held daily patient management conferences where clinical challenges and operational information, as well as some of our anecdotal experiences and important pieces of information, were exchanged. Some of these included the need to protect central concentration phenylephrine infusions from the light or the importance of recognizing when peripheral phenylephrine infusions were running at such a high rate that they were at risk of running dry. These conferences could not and did not replace explicit handoff. They did facilitate smoother transitions in care as we were cycling on and off day and night shifts with a pretty good frequency. With respect to unit clinical communication, we preserved our practice of huddles at the start of each shift with all the members of the interdisciplinary team. There we would exchange information about open beds, any off-unit studies or procedures that were planned, any anticipated arrests, and whether there were any exigent circumstances that might allow for familial visitation. As part of the modification to the physical space, communication between bedside staff and team members outside of the room was challenging. We had installed HEPA filters that were very loud, and it made it difficult for folks outside of the room to hear what was going on inside the room. To overcome the noise and reduce the need for multiple personnel to enter the room for supplies or to answer questions, we used two-way radios and communicated medication infusion dosing in the latest ventilator settings by writing on the glass windows. Ultimately, I'd like to believe that we collaborated well and contributed meaningfully to the delivery of outstanding critical care at our hospital. In total, 60 patients with COVID-19-related critical illness received the majority of their care in the PICU. The median age of these patients was 67 years. Ninety percent of our patients required invasive mechanical ventilation, and in the context of our hospital protocols, they were essentially admitted to our unit specifically for management of COVID ARDS. Seventeen or 28 percent of the patients died, and 16 or 27 percent required renal replacement therapy. These rates were statistically no different from the outcomes of adults cared for by medical intensivists in the Tier 1 ICUs. So with that, I will close and would be happy to take your questions at the end of our presentations.

redeployment

intensivist

COVID-19 pandemic

collaboration

ventilator management skills