Today we'll be discussing how to build an operating room in a COVID-19 cohort ICU. My name is Patricia Luzon. I'm a Clinical Manager of Pharmacy, Critical Care, and Emergency Department Services at AdventHealth Orlando. And I'm Joshua Goldberg. I'm an acute care surgeon and surgical intensivist. Our ICU got converted from a surgical ICU into the second cohort COVID ICU during the initial surge of COVID-19 in March. As the census of critically ill COVID-19 patients increased, we recognized the need for procedures that are common to patients requiring mechanical ventilation for a long period of time. And we're using these procedures for tracheostomy, which is the most aerosol-generating procedure that we commonly do. There was also the anticipated need of percutaneous endoscopic gastrostomy, bronchoscopy, and the placement of tunneled hemodialysis catheters given the high incidence of renal failure in this patient population. Several options were discussed, including moving these patients to the operating room. However, that was thought to be too risky to other areas of the hospital, and the operating rooms are all positive pressure. We wanted to minimize patient transport and minimize exposure to other healthcare workers. The solution that was proposed and discussed with multiple team members was to create a mini operating room within the COVID-19 cohort unit. A multidisciplinary team was quickly convened to assist with the planning of this project. It included hospital and nursing leadership, surgery, the operating room, anesthesia staff, as well as nursing and pharmacy. Hospital engineering was deployed to help with the conversion. A negative pressure patient room was converted into the mini operating room suite, and adjacent family waiting room was converted into an anteroom for the donning and doffing of PPE. The hallway outside of these two rooms was partially partitioned off with a new wall with a HEPA filter placed in this mini hallway, such that members of the operating room team could go from the anteroom, where PPE was donned and doffed, into the mini operating room and back. An adjacent patient room was used for storage of additional equipment. From the standpoint of personal protective equipment, all team members inside the operating room suite wore PAPRs, Powered Air Purifying Respirators, as you can see in the image on the right. This included a surgeon, the second surgeon, which was initially a second attending, and once there was sufficient experience, a senior level resident became the second surgeon. Either the anesthesiologist or the nurse anesthetist, an OR circulator, and an OR scrub tech. In the anteroom, outside of the mini operating room, a second OR nurse was there for charting purposes, as well as to help with running for additional equipment, as well as the anesthesiologist available to enter the room if needed. Outside of the anteroom was an additional ICU nurse, a respiratory therapist, and the pharmacist in case there were any extra things that were needed by the team. After careful discussion with respiratory therapy, nursing, anesthesia, and operating room staff, the following was the list of equipment for these procedures. The patient would be brought into the operating room on the transport ventilator and the procedure would be done using total intravenous anesthesia while on the patient's transport ventilator. We used a Above Cautery device with connected smoke evacuation. We used a closed circuit suction system, procedure-specific operating room equipment as well. The imaging requirements included a C-arm for tunnel hemodialysis catheter placement and an endoscopy tower as needed for bronchoscopy and percutaneous gastrostomy. The cleaning process in between procedures was done by the team in the operating room such that custodial services did not have to be exposed. In between patients, the members of the team wiped down all surfaces as well as the floor. At the end of the day's procedures, an environmental services terminal clean was performed. OERs have their own dispensing cabinets, so we wanted to make sure this room had the same access to procedural and emergency management medications. We approached this from two perspectives. The first was controlled substances and frequently used medications for each case. For these medications, we created a virtual automated dispensing kit that contained fentanyl, midazolam, rocuronium, phenylephrine, and propofol, which were identified by the surgeons as the most commonly used medications during their cases. There were plastic bags on the automated dispensing cabinet that these medications were placed into and labeled with a patient sticker so that we could credit them later if we needed to. The second process was for emergency medications that would be used less commonly, but we wanted to be available quickly. For these, we built a specific COVID-19 drawer, and the contents you can see in the picture on the right, as well as the actual drawer itself below it. This was locked similar to a code drawer with the red or yellow pull tags. And then the next issue to address with it would be how it was stored so that it would be secure. The idea was to store in an uncontaminated area outside the OR and only use within emergency situations. Any contents that were utilized were replaced on a per-medication basis after each case and then returned to pharmacy at the end of each day to refresh the kit and make sure it was clean. The bag of frequently used medications that contained controlled substances was taken into the OR room for each procedure, which meant that any of the medications that were not utilized were then considered contaminated. We didn't want to waste these medications because there was drug shortage problems with many of them, and so we developed a decontamination process for them. This was a two-person process where the person inside the room double-bagged the dirty contents into a clean bag double-bagged outside the room. This was then returned to pharmacy for decontamination by following the same process we developed for our code cart medications. In this process, each medication was wiped with purple wipes from a designated dirty area in the pharmacy and then moved to a designated clean area after following the prescribed dry times on the wipes. The contents were then credited back to the patient, and if they were controlled substances, were reconciled with the procedural charting versus what was left over after the procedure. The second part of post-procedure management was patient management. So, for example, with tracheostomies, we were then able to wean sedation and pain-control medications as the patient tolerated, which helped with our drug shortage initiatives as well. For PEG placements, we were then able to switch IV medications to per the PEG tube and optimize tube feedings as well. To provide the specific example of our experiences at Advent Health Orlando, we identified this need around three weeks after our initial COVID-19 patients presented, and many were still ventilated. We were able to very rapidly create this opening of OR within six days from generation of the idea to the opening of the actual OR. Fourteen procedures were performed in the first week, averaging around three to five procedures per day. A dedicated COVID elevator was utilized to transport between two cohort units and minimize contamination. Some keys to the success were performing a group debrief of all involved personnel after the first day so that we could make real-time process improvements. And some examples of things that we changed were from using an OR table to keeping the patient on the stretcher to perform throughput time, and then also modified our contents of our medication virtual kit based on what was used in the first day. Open communication, flexibility, and open mind to create new processes and teamwork were huge keys to the success of this initiative. In order to address the problem of how to perform procedures on a COVID-19 cohort, we have provided an example of one solution, which was building an operating room inside the COVID-19 cohort ICU. Please feel free to contact us if you have any questions regarding building a similar procedure in your unit. Thank you.

operating room

COVID-19 cohort ICU

procedures

critically ill patients

ICU conversion