SCCM Resource Library-Year in Review: Neuroscience

Video Transcription

Hi, everyone. My name is George Lopez. I'll be introducing our speakers today in this session entitled Year in Review in Neuroscience. This will be centered around the COVID-19  and how it's affected both the neuroscience community and our intensive care unit patients.  So our first speaker, the topic is how neurocritical care was affected, adaptation of neurointensivists  and neuroICUs. Our second topic will be on the collaborative research efforts on neurological  effects of COVID-19. This is from both a US and an international perspective on collaborative  research. And our third topic is on the impact on the education mission, which affects our trainees, our house staff, and how the COVID-19 pandemic has affected education.  So with that, I will let our esteemed speakers begin. And thanks again for joining this session  in Year in Review. Thank you again. Hello. My name is Neha Dungayaj and I'm a neurointensivist  for the ICON School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York.  And it is my honor and privilege to be presenting at hashtag CCC50 for this amazing session on neuroscience Year in Review. I do have a few disclosures, but none of them relates  directly to the content that I'm going to present to you today. I do serve on the American  College of Chest Physicians COVID-19 Task Force, and I will be showing a couple of infographics  that we developed as part of this task force. So what is the objective of today's talk? How did COVID-19 affect neurocritical care? And how did we as neurointensivists and our  neuro ICUs adapt to the impact of COVID-19? Let's do a quick dive into what neurocritical care is. The first ICUs, when they started coming up in Denmark, France, and Germany,  they were closely managed by neurologists, anesthesiologists, pulmonologists, as several of these physicians were taking care of patients with polio. The comprehensive multi-system  critical care management of patients with neuroemergencies is what neurocritical care is all about. In the 1980s, the first neurological and neurosurgical ICUs were established at  major academic centers. Since then, we've come a long way. So I asked my Twitter colleagues, what comes to your mind when you hear about neurocritical care? And as you can imagine,  the usual suspects, strokes, paranoid hemorrhage, traumatic brain injury, seizures, EVD, and  then one of our astute colleagues also mentioned, that made me chuckle, neurocritical care is  about a hole in the head, and it's for monitoring for the need for some other type of hole in  the head. Otherwise, I'll make you with neuroconcerns. And I'd never thought about it like that before.  So what does a contemporary neurosciences ICU look like? The common types of patients  include patients with stroke, traumatic brain injury, patients who are recovering from post-operative,  who require post-operative care after complex neurosurgical procedures. And the common procedures  and devices that you'll see in a neuro ICU are very similar to what you'll see in any contemporary critical care unit. In addition, you'll see some dedicated neuromonitoring  devices like critical care EEG, transcranial Dopplers, invasive, non-invasive ICP monitoring, and to this, let's add hashtag COVID-19 and proning, because that's what we all had to  learn in 2020. The principles of neurocritical care, in my mind, had prepared us as neurointensivists  to contribute meaningfully to this mission of taking care of COVID-19 patients and to help our colleagues in critical care at large to not only take care of our patients, but  also to be able to take care of one another. The values guiding education in neurocritical care of practicing evidence-based medicine, lifelong learning, pushing boundaries, and  being really collaborative also helped us adapt quickly to the changing environment and to what this pandemic needed us to rise to. Neurocritical care's footprint in the  United States, I don't have a lot of recent data to show you on this, but in the pre-COVID-19  era, there were about 73 neuro ICUs, according to this paper published in 2012. And there are about 73 accredited fellowships across the United States as of 2020. The Neurocritical  Care Society released this position statement very early on in the pandemic to highlight what neurointensivists and neuro ICUs should be prepared for in the midst of the pandemic.  So what would we need to plan for? Of course, resource utilization. How are we going to prepare for the surge? How are we going to cohort the care of patients who are COVID-19  positive neurocritical care patients and non-COVID-19 positive neurocritical care patients, and redeployment  of our staff? How are we going to adapt our policies and protocols for screening and triaging  patients in the pre-hospital phase while upholding time is brain for all neuroemergencies? How do we leverage telemedicine? How do we adapt our existing protocols? How do we develop  new protocols in light of the rapidly evolving literature on COVID-19? And then adapting the Society of Critical Care Medicine's tiered staffing model to provide excellent care both  for COVID-19 and non-COVID-19 neurocritical care patients. When I reflect back on my personal  evolution and journey through COVID-19, looking at my Twitter timeline, I find a reflection of hope and my core values throughout the pandemic. And I wondered what would take us  through this crisis. Dr. Ashi Shah, the Dean of Brown University, recently tweeted about  truly trying to understand what the collateral damage of COVID-19 was having on our critically  ill patients and what the attributable mortality to COVID-19 could look like. On October 2,  2020, there were 7,000 critically ill patients in the United States. And on January 13, there  were 27,000 COVID-19 patients in the ICUs. What this essentially meant was while COVID-19 is directly killing about 3,000 to 4,000 patients every day in the United States, it's  also filling up ICUs across the nation and not allowing us to take care of sick non-COVID-19 patients who would have otherwise been in our ICU. So perhaps their mortality should  also be attributable to COVID-19. This is a dashboard that several of us have been following and have seen multiple times during the course of the COVID-19 pandemic. And we know the  total number of global cases has crossed a staggering 87.5 million with over 21 million cases in the United States alone. What does this mean for our ICU capacity? So we look  at our national ICU capacity and occupancy in recent times, from October to January 1, 2021, we do see an increase in our overall ICU capacity. But at the same time, we also  see that as the COVID-19 ICU occupancy goes up, the ICU occupancy by non-COVID-19 sick patients is decreasing. So again, the cost that our patients are paying due to the COVID-19  pandemic and specifically for non-COVID-19 positive neurocritical care patients, what does this mean needs to be studied? Several neurocritical care divisions are part of neurology  departments in their institutions. And this was a description early in the pandemic by the group at Columbia about how the department, how the neurology department prepared for  the COVID-19 pandemic and how they planned for redeployment and reallocation of resources. So this is a similar adaptation to a tiered staffing model that the Society of Critical  Care Medicine has helped emphasize for us to be able to take care of the surge in patients  throughout the pandemic. And as you can see at Columbia, the unit is a closed unit with 18 beds  with one attending and a neurology center team. What they decided to do was split the team into  neurology centered and COVID-19 centered team to be able to provide the highest possible care.  We similarly published, so our neurocritical care division sits in the department of neurosurgery and we similarly published our experience from the front lines. One of our  neurosurgery attendings, John Caridi, when he rotated with us through the COVID-19 unit, prepared a cheat sheet for how neurosurgeons could contribute to the front lines as elective  surgeries were being canceled in order for the hospital to take care of the surge of COVID-19  patients. And here's a picture of how we started using our plexiglass to document some of the data  for COVID-19 patients in our ICU. We were running two ICUs, one to cohort the care of non-COVID-19  neurocritical care patients and a COVID-19 ICU. This is just unpublished data from the beginning  of the pandemic from March 14th to April 12th. So about a month's worth of data. And as you can  see, the median length of stay in our COVID-19 unit at that point in time was seven days and  for our non-COVID-19 neurocritical care unit was about six days. And mortality for both of these  units is reported here. For the non-COVID-19 unit was about 14.2% and for our COVID-19 unit was about  18%. There was obviously strong collaboration between the departments of neurology and neurosurgery in order for us to, for the four neurointensivists who were staffing the Mount  Sinai Hospital neuro ICU to get deployed to staffing a COVID unit, who was going to staff  the non-COVID-19 neurocritical care unit. Again, a tiered staffing model where the neurointensivist  would be available by phone, but a neurosurgery attending was running rounds along with neurosurgery  and neurology team members. From the front lines, this is what neurocritical care looks like with  intensive monitoring, both invasive, non-invasive monitoring of patients with acute brain injury. And from the front lines, this is what COVID-19 looked like. So at the peak of the  pandemic in our ICU, which has 18 beds, it's a closed unit with 18 beds in a space meant for 18  patients at the peak of the pandemic in New York City, when New York City had become the epicenter  of the pandemic in the United States last spring. We had two patients in a space meant for one  patient and we were using our plexiglass to document a lot of that information. Of course,  with the limitations on family visitation, we adapted and used a lot of hospitals across the nation. We also use tablets in order to communicate with patients and their families.  As part of the SCCN's COVID-19 What's Next, preparing for the second wave, I presented  on the spectrum of neurological manifestations and how do we adapt our testing. And if we think  about the spectrum, of course, a lot more is known now about the spectrum of neurological  complications from COVID-19, how many of these are associated with COVID-19. So we had to stay  abreast with all of that literature and there are upwards of 5,500 indexed publications just on neurological complications of COVID-19. And if we think about understanding these  manifestations, we could understand them on the basis of pathophysiology or the time course or  the severity of COVID-19. Of course, everything right from strokes to seizures to secondary  systemic complications to movement disorders have been described associated with COVID-19.  And some of us who do have critical care recovery clinics will see patients with long-haul COVID.  For neuromonitoring, a lot of neuro ICUs had to adapt their ability to perform some testing  studies, some diagnostic studies, both imaging, electrophysiological studies, EEG or ultrasound studies in the face of COVID-19 because of safety concerns as well as availability.  And some of these things with respect to adaptation to the clinical exam, particularly for patients in the ICUs, adapting the exam for patients who are deeply sedated and paralyzed,  at least checking their pupils to identify which patients are going to need to be scanned and need  more targeted neuromonitoring. The American Academy of Neurology released this important  statement on how the pandemic would affect our ethical duties as neurologists. And several of  the members of this particular committee, this joint committee of the ANA and the Child Neurology  Society, along with the Neurocritical Care Society's ethics committees released this position statement and several of the members here are neurointensivists. And they commented on  how we may need to adapt to providing care for patients who we think would benefit from our care when our resources are strained and how to continue leveraging  time is brain to provide timely and appropriate care while faced with this pandemic. Several international guidelines were also released, including this joint position statement  by the Neurocritical Care Society of India, as well as the Indian Society of Neuroanesthesiology  and Critical Care, again addressing everything right from PPE to adapting care to provide  care both for COVID-19 and non-COVID-19 patients with a special emphasis on what to do with the peri-op period and peri-angioperiod for these patients. Adapting our ICUs  I'm showing you a snapshot of what happened to our ICU. So all our ICU beds were converted to  negative pressure rooms. The traditional ICU units prior to the COVID-19 surge, we had 94 beds at the Mount Sinai Hospital. And after COVID-19, at the peak last spring,  we had 240 beds, which included non-traditional critical care spaces, for example,  vacuum spaces that were also converted to provide care to critically ill patients.  Here's an experience from Abu Dhabi, where they have 72 ICU beds, which were expanded to 130 beds  to take care of COVID-19 patients. Their 24-bed neurocritical care unit became a COVID-19 ICU, and they had a special focus on COVID-19 patients with neurological complications.  A recent survey conducted by several members of the Women in Neurocritical Care  group of the Neurocritical Care Society tried to identify clinicians' perception of the practice  changes for stroke and neurocritical care during COVID-19. And according to the respondents,  almost 40% respondents were taking care of patients who were either PUIs or COVID-19  positive. And several of the ICUs had to be converted to providing care for COVID-19 patients  as the MCUs were overflowing. Many hospitals also combined their specialty ICUs with all COVID-19  patients of PUIs to cohort the care in one area. Let's shift gears and talk a little bit about  communication in crisis, because throughout this pandemic, it was very important to stay up-to-date with the information as it was rapidly evolving, as well as to acknowledge  the uncertainties that were coming with this pandemic, not only for our patients, but also for our teams. So how did we communicate in crisis? So this is again an example of  communication from Columbia's neurology department and how they were conducting interdisciplinary meetings and what the themes were in these meetings. And here's a snapshot  of what we did at our center at a health system level, at a hospital, at Institute of Critical  Care Medicine level, at the level of different departments, as well as at our Neurocritical  Care Division level. Of course, there were lots of different channels of communication that were  being used along with making sure that we had electronic repositories of the resources we were  developing. And a lot of our meetings, both for social distancing purposes, as well as to ensure  that communication lines were open 24-7, transitioned to Zoom. So again, just to highlight  one of the key elements of our ethical duties as neurologists. So when we uphold time is brain,  there are several community hospitals that we anticipated would be overrun by COVID-19,  and to ensure that they had the kind of support they needed to transfer patients, for example,  to comprehensive stroke centers to provide timely care for patients who would benefit from acute  stroke intervention would be imperative. So in the next few slides, I'll show you how we adapted to providing that type of care. Similarly, making sure that we were aware of equity,  diversity, and inclusion. We know that COVID-19 magnified the racial and ethnic disparities in healthcare, and providing that kind of inclusive care, particularly at a time when  our resources were going to feel the burden of this rapidly evolving pandemic, was imperative. So we published this paper in the American Academy of Neurology's Neurology Journal.  So how did we as a health system adapt to providing care and cohorting and transferring patients? So prior to COVID-19, this was our model. We had multiple different centers of  excellence for different disease processes throughout New York City. And our program that was established in 2017, the Neuroemergencies Management and Transfers Program, to provide  the right care to the right patient at the right time, we did our very best to uphold that in the  midst of the pandemic. So when we compared the diseases, so we saw upwards of 300 to 350  patients in the same time period. So from January through March, and March through April, March 15  to April 30, if we think of that as a post-COVID-19 period, a peak in New York City,  we compared the total number of disease processes, the total number of patients that we transferred,  and we saw a surge in the total number of strokes that our health system took care of.  But the total number of patients that we transferred did not decrease, because we were transferring patients from other hospitals as well that usually do not refer patients to us,  and we were only able to accommodate life rescue transfers. But despite all of that, our transfer times did not change for life rescue transfers.  There was another disturbing trend that was reported by several neurology, neurosurgery,  neurocritical care divisions throughout the United States, as well as in several parts of the world,  that the total number of patients presenting with stroke and seeking acute stroke care, this is a report from Northeast Ohio, there was a decline that was seen after there was a  declaration of state emergency, and this observation could be attributed to a true decline in stroke incidence, this is what the author speculated, or because patients were  just not showing up to seek medical attention because of the fear of contracting COVID-19. We adapted our health systems workflow, this is a publication from AJNR,  with an elbow alert, the INR team would be activated, the COVID status would be determined,  patients would still be transferred and triaged as per our pre-COVID-19 policies, and patients would be transferred over for thrombectomy to one of our comprehensive stroke centers,  and at Mount Sinai Hospital, which is a comprehensive stroke center, we would cohort  the care of the COVID-19 patients into our COVID-19 neurocritical care unit that was providing care  for both COVID-19 positive neurocritical care patients, as well as COVID-19 non-neurocritical  care patients, and if the patients were COVID-19 negative, then they would go to our neuro ICU,  if they were a COVID PUI, they would go to a negative pressure room, and if they turned out  to be positive, then they would be transferred to the COVID-19 ICU. Incidentally, even though  testing was a challenge for these patients who were getting CT-CTAs as part of our acute stroke  protocol, identifying that these patients had infiltrates classically seen in COVID-19  could be identified in the imaging, the CTA imaging that included the apices of the chest  bilaterally. A quick word on hemicraniectomy and cerebral edema, so these patients should be  offered, so COVID-19 patients should be offered decompressive hemicranie if they are developing  malignant cerebral edema, exactly using the same criteria that you would have used in the pre-COVID-19 errors, and this was a case series from our center. Hemorrhagic stroke, so our  colleagues over at NYU described hemorrhagic stroke, and at a point in time when there was a lot of discussion about starting therapeutic anticoagulation in patients with COVID-19,  even if they did not have a confirmed VTE, this of course now with in light of more recent studies,  the current recommendation of course is to only anticoagulate if there is a proven diagnosis of a  VTE, whether it's a DBT or a PE, this does give us some pause. So in summary for what does COVID-19  neurocritical care mean, so of course being able to identify associated clinical findings, being  able to cohort the care of COVID-19 neurocritical care patients and COVID-19 patients who may develop  associated neurological complications in a neurocritical care unit that's been converted into COVID-19 may be one approach that other centers have also successfully been able to  adapt to. There are several challenges when it comes to diagnostic considerations, of course  you will need to have a high clinical suspicion for diagnosing neurological complications of  COVID-19, as well as a high clinical suspicion for screening patients who present with neuroemergencies  with COVID-19. So shifting gears now to post-COVID-19 care, so there are millions of ICU  survivors who are at risk of developing post-intensive care syndrome even in the pre-COVID-19  era, and with COVID-19 our suspicion is when we tie in more sedation, more paralysis, less  mobilization, less family visitation, we anticipate that these patients will be at a higher risk of  developing post-intensive care syndrome. Several centers across the United States and in the world  have critical care recovery clinics. We are at Mount Sinai, we have our critical care recovery  clinic that is part of the Society of Critical Care Medicine's Thrive Network and more recently  the Cairo Network, and we adapted our model to providing care via a telehealth paradigm.  Social media, and just a quick word about social media and donations from patients, families,  from different team members, that really was another profound, had a profound impact on neuroICUs across the country. A special, a very special campaign that was started by  Ruchi Raja, Asma Mohi, Aarti Sarwal, Jaidev Sindholia, and Devin Burke, and several others, and Daniel Thomas,  several others who ensured, they started a GoFundMe campaign, raised about $10,000 in 24 hours and were delivering meals to several neuroICUs across the country.  I would like to wrap up with how COVID-19 really magnified the team spirit and collaboration for  all of us, as not just within our own teams, but across our hospitals and health systems, and here's a little post written by, here's a little snapshot from a post written by one  of our nurse practitioners, Mary Prosciutti, who was also a neuroICU nurse for a long time,  and now is a nurse practitioner in neurosurgery, and what she highlighted, that charity, valor,  the true art of medicine that was on display, really emboldened our resolve to overcome this pandemic, and the COVID-19 ICU together brought us in this noble fellowship  and in this mission. So with that, I'd like to, I'd like to stop and thank all our patients and families, and would like to dedicate this presentation to each and every person here  and across the world over that's fighting COVID-19. I'd love to take some questions during  the Q&A session, and here's my, here's my information. Thank you again for this opportunity,  and hope you enjoy the Congress. Hello, everyone. My name is Sherry Cho. I'm the Associate Professor in the Departments of Critical Care Medicine, Neurology, and Neurosurgery.  I want to thank the organizers and the chairs of this session for the opportunity to speak here,  and I will speak to you about collaborative research on neurological effects in COVID-19.  These are my disclosures. So why do we suspect neurological involvement with a respiratory virus  like COVID-19 or SARS-CoV-2? Let me take you back to the last global pandemic that everybody  remembered, the 1918 influenza pandemic. Following the pandemic, there was this mysterious  illness, encephalitis lethargica, that affected about 5 million people, and it's a sleeping  sickness where the patients are conscious, yet motionless, achonetic, mute, in a coma-like state.  Even though the proofs were never found, based on the close association with the pandemic,  with the influenza pandemic itself, many people suspect that this is a post-viral syndrome.  The fact is, many respiratory viruses actually have neurological manifestations. Influenza, RSV, enterovirus, even our seasonal cold, which, by the way, is a human coronavirus.  If I may take you back to the original SARS pandemic with SARS-CoV, this virus is known to cause encephalopathy and seizures, and on autopsy and histology, we have isolated  particles of this virus in the brain tissue itself, and we know that some coronaviruses are neurotropic, so it is very reasonable to assume that SARS-CoV-2, the virus that  causes COVID-19, may also have a neurological profile. As of late December, we now have 77  million cases of COVID worldwide. With a pandemic of this size, even if the neurological syndrome is rare, multiply  that by 77 million. We're talking about a big public health crisis, particularly because whenever the neurological system is involved, mortality is high,  morbidity is high, and recovery is at best incomplete in most cases. Now, as we move into April or May of the pandemic year, we begin to see reports  like this, where seemingly young and healthy people would turn up with large strokes that require emergent procedure and with no apparent risk factors. If we  start looking at the case reports of various neurological features that began to accumulate, at about middle of the year, we had the most number of case  reports about Guillain-Barre syndrome, followed by ischemic stroke, encephalitis, and a smattering of other conditions. But the number of case reports doesn't  really reflect the prevalence of this condition in the general population. This is highly dependent on people willing to report these cases. If we  look at an autopsy population, by far the most common neurological pathology that was seen in this population was acute hypoxic ischemic damage.  So, looking at these different data and different populations, we know that there are some major critical knowledge gaps that we have to cross. What are the  major phenotypes of neurological involvement of COVID-19? What is the prevalence of these conditions? In other words, how big a problem is this? What  causes these symptoms? Are they actually due to direct effect of the virus or are they coincidental? Importantly, how do these manifestations  affect the patient's outcome? And who are the patients who are at risk for developing neurological complications from COVID-19 and why? We know that we  needed to answer these questions quickly and we needed to run a study and launch it in the middle of a pandemic and collect data in conditions like this.  As we consider the rapid study development in a pandemic, there are a few unique features that we must think about. We mentioned urgency. We know that  we must operate under an extremely compressed timeline to complete the research and deliver robust results because we don't have time for wrong  results to misguide us. We absolutely need to focus on feasibility. In a pandemic like this, we know that a lot of the data need to be collected by  frontline clinicians who are right at the patient's bedside. Therefore, we have to minimize data collection burden. We need to optimize data that can be  collected remotely from a research team using medical record and then phoning in to the frontline workers to get the data that's missing. We also need to  minimize missing data. In a pandemic where many health systems are overwhelmed, what may make it to the electronic medical record or what may  make it to the bedside clinical record is unpredictable. We needed to focus on the most common data elements universally available and despite how  limited it is, despite how overwhelmed the health system is, we still have to consider regulatory approval for all human studies. So in a pragmatic design,  we ask all sites to seek their single-center exempt IRB approval as quickly as possible and that would allow the local sites to begin local data  collection as soon as possible without the ability to share it centrally with the central coordinating center. In parallel, here in the central  coordinating center, we then set up the multi-center IRB process and began executing data use agreement, but we did not want this process to hold up the  beginning of data collection from all the sites. We absolutely had to think about safety. Our data collection must not increase personnel exposure risk to  SARS-CoV-2 and we cannot use up the limited PPE supplies that have to be reserved for our frontline workers. And finally, we consider diversity. In a  global pandemic like this, it was important for us to capture diversity across population, across geographic regions, across provider types, and socioeconomic status.  When it came to designing the study, even data elements required special consideration. For example, inclusion criteria. How do we define COVID-19  population, especially at the beginning of the pandemic where testing was very limited? We really did not know who are the people who should be included. We  took a pragmatic approach. We decided we would include anybody who was test confirmed positive with SARS-CoV-2 infection and also anybody who had a  clinically diagnosed COVID-19 syndrome who may not be tested. We also restricted our population to hospitalized patients only in this stage of the study because  this group of the patients were more uniformly tested compared to people who are in the community. Our data definitions also need a special  considerations. At the beginning of the pandemic, many of our routine diagnostics were limited or the processes were very disrupted. So  without these diagnostics, what do we do with case definitions? We again took a pragmatic approach and we decided we will focus on clinical phenotypes. So  whatever data we capture must be available through history or bedside clinical exam and we cannot rely on the availability of diagnostic testing being  available. At the same time, we also do not assume that there is a neurological specialist who can be there collecting these data elements for us in the middle  of the pandemic. So the data elements we selected had to be easily available and consistent by examination through any frontline clinician, whether or not they  have neurological expertise. This slide illustrates the early phases of this global consortium, the GCS NeuroCOVID Consortium, and as you can see, the  consortium was conceived shortly after we declare US national emergency here and within a matter of five weeks, the number of registered sites grew  exponentially. About four weeks into the consortium, we opened a pediatrics arm as well and now we have a consortium study that covers all of the population, both  pediatrics and adults. Because we wanted to operate in a compressed timeline and and to adapt to the shifting ground under us in terms of the amount of  information, new information coming through on COVID-19, we had a tiered approach. Our tier one study, which is ongoing right now, is what what we call  the study during the time of war. This is a highly pragmatic study where we just want to capture the basic clinical phenotypes and prevalences of the  most common syndromes seen in COVID-19. As we conduct tier one, we're designing and getting ready to launch tier two, which will capture additional clinical  information that we were unable to capture in tier one, further hone in on the details of our clinical phenotypes, include diagnostic information, and more  importantly, include outcome information beyond acute hospitalization. As we run that tier, we would design and get ready to launch tier three, which is our  translational experimental arm, where we can use translational experimental technologies to query into the disease mechanism and hopefully begin to discuss  and investigate therapeutic options. The design and the rationale of this tiered approach has been published, and at the end of my talk I will share the  link with you. The current status of our GCS NeuroCOVID consortium is here. We have 234 registered sites, 131 of which are adult sites and 103 are  pediatric study sites. We have lead investigators from the United States and from Europe. The central coordinating center for both the adult and pediatric  studies are here at the University of Pittsburgh. We're very fortunate and very grateful to have great collaborative partners globally. We have a formal  collaboration with the European Academy of Neurology Energy Network. We also have collaboration with Latin American Brain Injury Consortium and the POSPEL  Network, which is also located within Latin America. We're endorsed by the Neurocritical Care Society and the Neurocritical Care Society Research  Central and Research Network. Globally, with our consortium partners, we are currently at 450 registered sites. This map depicts where the global consortium  is as of July of 2020. In the green dot, you can see these are the adult study sites for GCS NeuroCOVID consortium. The pink dots are pediatric sites, and  the yellow dots are our European partner sites by the EAN. I should mention that this map was drawn before our Latin American partners joined us, so there  should be a lot more sites now in this map. I want to specifically mention our pediatrics study and the pediatrics arm of the consortium. We're very grateful to  partner with PNCRG and a group of fantastic pediatric intensivists and investigators from across the globe who took the adult study, designed a  pediatric parallel and equivalent study with data elements and outcome elements appropriate and relevant for the pediatric population. Below the  slide, you can see there's a link to their web page where you can learn more about the pediatrics study. One of the most important things we decided we  needed to do early on is to harmonize our data elements and data definition with all the other large trials out there studying COVID. This will give us  the opportunity later on to merge our data and combine our data to form robust scientific conclusions. As I mentioned, one of the first things we did was  harmonize our data elements and data definitions with our partner EAN Energy study, with whom we already have 80% overlap in the first stage of our  study. In addition, we're working with the Canadian Critical Care Trials Group, Possible Network, LABIC, the World Health Organization, as well as the general  COVID trial networks to combine and to harmonize as many of the data definitions and data elements used as possible.  Part of this effort to make sure we have global presence and standardize our data definitions and data elements, we have translated our adult and pediatric CRFs  to Spanish and Portuguese.  On this slide, you can see some of our representative publications and the final link will take you to the web page on the Neurocritical Care Society  website, which will provide general information about the different studies that are running through the consortium and an opportunity for your site to  register. Any acute care site that is currently providing care to COVID-19 patients are eligible for registration with our consortium. I want to  take a minute to recognize all of my co-investigators for the GCS NeuroCOVID consortium, our adult team and our pediatric study team.  A consortium of this size could not be achieved with just the principal investigators. Here, I just want to recognize and acknowledge all of the  team members, the research team members, volunteer residents, students, colleagues, the Neurocritical Care Research Network and our resources here locally at the  University of Pittsburgh for supporting this consortium. With that, I will thank you and take any questions. Hi, I'm Angela Hay Shapshak from the University of  Alabama at Birmingham and I'm going to give a brief rundown of the effect of the COVID-19 pandemic on neurocritical care fellowships. I have no relevant  disclosures to discuss. Briefly, here are the objectives for the discussion. I'll touch for a moment on the response of various graduate medical education  accrediting bodies to the COVID-19 pandemic and then relate those changes to the effect on neurocritical care fellowships. Briefly discuss the response  of the neurocritical care community to the challenges on fellowship recruitment and the matching process. Finally, touch very briefly on our recent efforts to  support graduating and currently enrolled fellows in neurocritical care programs. I think the words unprecedented and transformational have been  somewhat overused since the COVID-19 pandemic was declared in March, but certainly it has been both transformational and unprecedented with  respect to graduate medical education. This is just a screenshot of a quick  PubMed search trying to look for the terms COVID-19 and graduate medical education which revealed 804 publications. It's actually over 4,000 if  you look just at medical education as a whole. The Accreditation Council for Graduate Medical Education came out with a statement regarding the COVID-19  pandemic very early in the game. This was back in March where they recognized that  the unique stresses that teaching hospitals are operating under will lead to some significant changes to training programs and to the functions of  residents and fellows in their clinical experiences. At that point in time, they identified three stages of the pandemic that were relevant to sponsoring  institutions. Stage one was defined as business as usual, minimal effect of the pandemic. Stage two was a designation for institutions that were seeing an  increased but manageable clinical demand. Stage three were those institutions that were operating under a state of emergency essentially where  the ACGME recognized that the increase in volume or severity of illness was creating an environment where the learning environment needed to be  redirected to focus entirely on patient care. Now you'll note that this webpage has since been archived and that's because really there aren't any  institutions at this point in time that are still operating under stage one. At this point in time, institutions can apply to the ACGME to be recognized as  operating under an emergency categorization or you're essentially operating at stage two. So I can tell you here at UAB we're under an emergency  situation at this point in time. However, even for those institutions that are operating under emergency circumstances, the ACGME has identified with their  calling for ongoing requirement priorities. So the first of these is that we are still obligated to adhere to work hour restrictions. Those are unchanged  despite the pandemic situation. We are obligated to provide adequate resources and training to residents and fellows and they specifically stated that this  includes access to PPE and adequate training in its use. It remains required that we provide adequate supervision for fellows and trainees. That's fairly  self-explanatory. But the piece that's most relevant to fellowship programs  involves the stipulation about fellows functioning in their core specialty. So essentially, a fellow can function as an attending in his or her primary  specialty if they are ABMS board certified or board eligible, if they have an appointment to the medical staff at the sponsoring institution, and if  the core time or the total time they're spending as an attending in their core specialty is less than 20% of their annual educational time. So there was a  recognition on the part of the accrediting organizations that the needs of the pandemic would require residents and fellows to be redeployed and might  impact their ability to continue with some required rotations, which could have an impact on board eligibility. However, as you know, the ACGME is not  the arbiter of board eligibility, that responsibility falls to individual organizations. So the ACGME directs interested parties to the websites of  the various ABMS member boards to obtain more information. So with respect to the ABPN, specifically, they have stated that they will largely defer to program  directors to stipulate whether or not a particular resident has completed the specialty training required to meet criteria for graduation. So how does all  of this pertain to neurocritical care? Well, as many of you in the audience may know, there is an ACGME pathway that is in development for neurocritical care,  the program requirements have been posted for public comment as of December 21. But at the moment, most neurocritical care, or fellowships are  accredited through the United Council for Neurological Subspecialties, which has tried for most of its existence to closely adhere to ACGME guidelines. And  they specifically utilize some of the same requirements regarding work hours, and the requirement for supervision and so on. The UCNS has gone on to state  that UCNS accredited training programs may choose to graduate currently enrolled fellows, despite the fact that they may or may not have met the minimum training  requirements, provided that the fellow is competent to practice the specialty independently. So like the ABPN, they're deferring to the program director in  this regard. I'm not actually sure if any neurocritical care programs have taken the UCNS up on this opportunity. However, it is available to us. To move on  briefly to the effect on the neurocritical care recruitment and the match. As you'll see from the timeline, the World Health Organization declared  the pandemic really when we were in the middle of the San Francisco matching process for the neurocritical care match for 2021 positions. So the match cycle  opened in October. And as you can see, it's typically about an eight month process. So programs were kind of all over the map with respect to how many of  their interviews they have been able to complete by the time the pandemic was declared. There was quite a bit of discussion among fellowship directors  about the utility of moving the match date to enable programs to adequately interview applicants. Some program directors in harder hit areas did feel  that prolonging the match cycle would be beneficial to them. However, there was a recognition that really it was the applicants who had the most to lose. So  in recognition of that, program directors agreed to defer to the decision among the applicants. And with the assistance of the San Francisco matching program  personnel, we were able to survey all applicants who were registered for the 2020 match cycle for 2021 positions in early April of 2020. And we achieved a  pretty good response rate. So of the 113 applicants who were registered for the San Francisco match, 66 or 58% of the applicants responded. And in response to  the major question about whether it would be helpful to postpone the match date, about 73% of them said no. They would prefer to stick to the original  timeline with the match date in June of 2020. Of those who did feel that there was some utility to moving the match date a little bit later, you can see  there was a lot of heterogeneity around the preferred match date. Interestingly, July is not an option because the San Francisco match is essentially closed  during the month of July. But of the 20 or so applicants who weren't in postponing at some, they were waiting as late as November. So I think that is  informative. And so were some of the responses to the open questions.  Applicants recognized that in person interviews were valuable for assessing the culture of an institution. And some expressed concerns about formulating a  rank list based on incomplete information. But for the most part, most of the respondents to the survey felt that programs were able to rapidly  transition to virtual interviews and that they were able to gain adequate information through that process. Several expressed concern about the  financial stress, which would be a result of resuming in person interviews. And quite a few were very concerned about the logistics of trying to move to  a new institution on a shorter timeframe, largely because they were concerned about licensure issues, visas, and many people who are in the position  of trying to secure employment for other family members. And lastly, several  applicants noted correctly that there was a fair amount of uncertainty regarding the future of the pandemic and they were unclear whether postponing  the match date would actually result in any significant benefit under the circumstances. But this impacts a larger national movement to attempt to  homogenize the timeline among neurology fellowships. So those of you who are neurointensivists that are not from a neurology background may or may not be  aware of this, but the American Academy of Neurology has been working for the past year or so to attempt to create buy-in among all the subspecialty  communities to try to develop a consistent fellowship timeline for all neurological fellowships. And specifically, their proposal suggests  that fellowship programs should agree to begin the application process no earlier than March 1 of the second to last year of training, so PGY-3 for  adult neurology residencies, with an offer date or match day for programs that use a matching program of no earlier than August 1 of the final year  of training. So they have been working to obtain buy-in for this proposal and the AAN has decided to target headache medicine, movement disorders, and  neuromuscular diseases in the first wave, which is occurring currently. From what I've been told as of an update from July 31st of 2020, headache medicine and  movement disorders have largely committed to implementing the time frame as proposed by AAN. Neuromuscular diseases has agreed to the March 1  opening date for their application process, but is sticking with a June date for the match. So this is relevant to neurocritical care programs because we  will be in the next group of specialties that the AAN will be targeting and shortly the neurocritical care community will have to come to a consensus about  whether we plan to adopt this time frame or some altered time frame for the upcoming match for 2023 positions, and that is a subject of active discussion  among the fellowship directors in neurocritical care. So it's interesting to discuss the effect of the pandemic globally on neurocritical care recruitment.  This is data that was supplied by the San Francisco Matching Program, where you can see that the number of applicants in the Neurocritical Care  Fellowship has doubled over the past 10 years and has been trending up fairly consistently from 2010 to 2020. Similarly, the number of participating  programs has been on the rise, and as of 2020 there were 60 programs that were participating in the match. I am pleased to report that in spite of everything  that's been going on this year, we actually have four new neurocritical care programs that have been UCNS accredited in 2020, and the  number of total registered applicants for the ongoing match cycle has increased by 16% from prior years. So we are now up to 131 registered applicants  for the current match cycle as opposed to 113 last year, and I'm hopeful that at least some of that has to do with increased exposure to critical care  patients that a lot of residents are seeing as a result of the ongoing pandemic. However, it's important to note that there  have been some perhaps negative effects of the need to transition to virtual interviews and so on, as reflected in the ongoing residency match cycle. So I'll  share a brief quote from a letter from Alice Whelan, who's the chief medical education officer at the AAMC, and this letter was released December 18th, where  she notes that the AAMC has detected a maldistribution of residency interview  invitations, wherein students in the highest tier are receiving and accepting a higher number of interviews per person than was common in the past, and that  appears to be taking place at the expense of applicants in the middle and lower tiers of their medical school classes. And that's perhaps not  surprising, given the fact that there are fewer costs associated with accepting and attending a virtual interview than there used to be when  applicants would travel to the program. But that could have a significant negative impact on match results, leaving some applicants without a  program and leaving some programs unable to fill. So that might be something to keep in mind for neurocritical care program directors heading into the  current match cycle. So the AAMC recommendations were for programs to expand the number of offers interviewed and for institutions to encourage  students that may be in that top tier group to decline interviews at programs that they don't think are a priority, but it remains to be seen whether that  is going to occur. So lastly, the program directors and the Neurocritical Care Society have been aware of the impact that this is having on our  fellows and our graduating, particularly those who are embarking on a job search under these rather unusual circumstances. So there are a couple  of initiatives underway to try to help currently enrolled fellows cope with this. This is a screenshot from our first ever Neurocritical Care Society  Virtual Career Fair, which I was privileged to be a part of. And I was grateful to members of the trainees section, as well as members of the  Neurocritical Care Society staff who helped us to put this together on relatively short notice. We were able to get approximately 40 of our currently  enrolled fellows to attend and we received some very good feedback about this. This will end up being the first of hopefully at least a few similar  events with one in the near future is intended to focus on visa issues. And we are investigating within our program directors organization, the feasibility  of providing webinars and other educational opportunities for programs that are unable to continue their current didactic program under the  current circumstances. And unfortunately, with that, I believe I'm out of time. But I would once again like to thank the organizers for giving me this opportunity to speak.

Video Summary

In this video, three speakers discuss the impact of COVID-19 on the neuroscience community and neurocritical care. The first speaker discusses how neurocritical care was affected and how neurointensivists and neuroICUs adapted to the pandemic. The second speaker discusses the collaborative research efforts on neurological effects of COVID-19, both in the US and internationally. The third speaker discusses the impact on the education mission, including the effect on trainees and house staff. The speakers highlight the challenges faced by neurocritical care units in terms of resource utilization, screening and triaging patients, and adapting protocols and procedures. They also discuss the impact on patient care, including changes in length of stay and mortality rates. The speakers emphasize the importance of communication, both within interdisciplinary teams and with patients and families, and the need to adapt to the rapidly evolving literature on COVID-19. They also address the ethical duties of neurologists and the need for equity, diversity, and inclusion in providing care for all patients. Overall, the speakers highlight the resilience and collaboration of the neuroscience community in the face of the pandemic.

Asset Subtitle

Neuroscience, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Analyze how COVID-19 responses required adaptations of neurointensivists and neuro-ICUs
Review the international collaboration on neurologic effects of COVID-19
Discuss changes to the neurocritical care match in response to COVID-19 restrictions

How Neurocritical Care Was Affected: Adaptation of Neurointensivists and Neuro-ICUs
Neha S. Dangayach

Collaborative Research on Neurologic Effects
Sherry H. Chou

Impact on Education Mission
Angela H. Shapshak

Meta Tag

Content Type Presentation

Knowledge Area Neuroscience

Knowledge Area Crisis Management

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Tag Resource Allocation

Tag Education

Year 2021

Keywords

COVID-19

neuroscience community

neurocritical care

collaborative research

patient care

communication

literature

resilience

collaboration

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