By Peter J. Papadakos, MD, FCCM, FAARC
As an individual who studies the effect of technology on the practice of medicine, one of the most amazing aspects of this terrible pandemic is how the medical community around the world has joined together as one to share protocols, guidelines and disaster plans with each other. I have a broad network of colleagues in both trauma critical care and neurocritical care, and it’s been outstanding how rapidly we all joined together via e-mail, WhatsApp forums, Zoom conferences and others to share our patient care experiences.
We circle the globe from every U.S. state, Canada, South America, China, Japan Korea, Italy, Spain and others. I’ve been able to share this international information almost hourly with my own critical care team and my personal contacts to get the latest medical information out to aid the care of our patients. It is fantastic to get advice of international leaders and societies on some of the basics in the care of such COVID-infected patients. It frees us from having to develop guidelines for our own unit or facility and be able to focus on patient care.
It is wonderful to get ideas on how to best preserve PPD equipment that I never knew could be reused using operating room sterilization and UV technology. Colleagues shared how local clothing industry, local tailors, sewing circles and handcrafters could be martialed to create surgical masks and gowns by working at home. I am old enough to remember when I started in surgery that gowns and masks were made of cloth and recycled within our own hospital. Maybe this is a lesson to all of us that disposable items can be easily displaced. In my own community, Hickey Freeman, a luxury clothes maker, has put its business online and had employees work from home to create both gowns and masks. This may be a key contribution to our area hospitals. We should mobilize local resources and volunteers to spread this grassroots model to every city and town to support the effort to get PPD supplies to healthcare providers. Local brewers and distilleries have repurposed to make hand sanitizers to replace their local business.
Another key aspect from this digital idea sharing is models in staffing and logistics. The key message is that this COVID challenge requires a deep reorganization of our work and staffing models, as they are practiced now. We do not wish to let administrators think they can run business as usual. In few days, we may all be dealing with a COVID surge. This is not just an ICU problem; it is a hospital-wide and system problem. All over the world, elective surgery has been stopped prior to even the first inflow of COVID patients — preparation has become proactive versus reactive. Hospitals in Toronto have run simulations and developed a surge plan — why not copy and repurpose them to fit your local needs? They will shut down the ORs and move as many patients as possible from general wards. Some health systems have developed plans to use ambulatory surgery centers as patient overflow areas if the hospitals are overwhelmed with patients to decompress there wards. Anesthesia machines and anesthesia providers may reinforce ICUs to care for patients in respiratory failure several ratio models as to intensivist to anesthesia provider have been put forward. One model has one intensivist supervising 10 anesthesia providers. This may put more ICU beds on line more rapidly than building new health facilities.
“How do I staff my ICU with providers?” is another question being discussed on almost an hourly basis. The key takeaway is the ability to preserve as much staff as possible for the surge. As the number of COVID-infected individuals in the community raises, it raises the chance staff members may become sick. This has been reported throughout the world.
Departments need to have plans in place to have blocks of staff in reserve. In other words, have two-thirds of your critical staff at home and away from hospital patients, so they can replace staff as they become ill and fatigued. Cut down on rounding teams, use non-ICU providers, such as surgeons, to gain vascular access, anesthesiology staff to do all hospital intubations and post-operative nurses to reinforce ICU nurses.
Many facilities have developed dedicated anesthesia teams that are responsible to intubate every patient using high level PPD protection. As we have learned from Asia and Europe, one of the most common times of contamination of ICU staff is during intubation. The common axiom of “the more you do something, the better you get” comes into play by using dedicated senior level providers. Consultants can also be utilized from home via Zoom and other video conference platforms. One city stopped its competitive model and began sharing consultants via electronic means across the network borders. Draw on each other’s strengths as an example. There may be a world famous expert on ARDs management in the hospital down the street, and your community may be better served if that individual can aid in complex ventilator care of 200 patients and not the 12 in their home ICU. This can also be expanded across an entire state or even a county. Each hospital and community can develop its own plan to modulate its staff based on local resources and means.
Lessons can be learned if we are able to share and use the lessons learned from others who were the first to battle the COVID pandemic. This may be a model that we can use for the next pandemic, so we’re better able to respond. Lessons learned now may safe millions later. The internet has never been so useful to healthcare providers as it is today.
Thank you to all the healthcare workers around the globe who are sharing their experience and knowledge to us all.