By Alexis Steinberg, MD; Matthew R. Leach, MD; Angela Hays Shapshak, MD; and Lori Shutter, MD
The Covid-19 pandemic has dramatically changed the practice of critical care, and neurocritical care has not been immune to these changes. As ICUs across the country experience a swell in COVID-positive patients, neurointensivists have been called upon to practice outside their normal scope, dealing with increased patient volumes and greater proportions of general critical care patients, despite ongoing acute neurologic emergencies.
We interviewed attending neurointensivists and neurocritical care fellows across the United States to find out how the COVID pandemic was affecting their practice. We found that most issues fell into one of two categories:
- Changes to recruitment during a global pandemic
- Changes in day-to-day practice for neurointensivists as hospitals deal with widespread shortage of all ICU providers.
Changes in Recruitment
The biggest and perhaps most obvious change to recruitment for neurocritical care fellows arrived in the digitalization of all interviews. This mirrors a cultural shift toward the digital predating COVID, but this was further catalyzed by implementation of social distancing. All programs universally attested to conducting every aspect of the interview process via video conferencing. Many programs are continuing to host pre-interview “dinners” and/or interview day “lunches” with fellows using these applications.
Despite reservations, most expressed few problems conducting these interviews remotely. The most common concern was providing an adequate/favorable impression of a program via the digital format, as most program directors felt that virtual interviews were adequate for them to evaluate candidates. While several programs from more heavily COVID-impacted areas favored delaying the match due to an increased workload impacting their ability to conduct even virtual interviews, 73% of applicants favored the current match date, and all program directors universally agreed on deferring to applicants, in a survey sent to applicants registered through the SF Match.
A perhaps more troubling but thankfully less common complication of this culture shift is an apparent increase in positions offered outside the match. Despite these being discouraged in the SF Match rules, there are general concerns that these agreements are happening with an increased frequency this year. Program directors fear that this shift may continue going forward and that it may significantly alter the landscape of the NCC interview process, with dramatic implications for the future of the recruitment process.
Fellows Experience in the ICUs
The clinical duties of neurointensivists nationwide have been greatly affected, both in terms of the patient populations cared for and day-to-day clinical operations. Similar to the interview process, patient care amenable to digitalization has been transitioned to this modality, with many institutions investing heavily in tele-consults, not only for tele-stroke — well established in the thrombectomy era — but also for tele ICU. The severe shortage of intensivists nationwide has forced a rapid maturation of the relatively novel tele-ICU model. Our own institution at the University of Pittsburgh has implemented a tele-ICU consult service for hospitals in New York City who must rely on non-intensivists as their boots-on-the-ground providers for many COVID-infected patients. This service is being staffed by intensivists from a wide variety of backgrounds, including our neurocritical care attendings and fellows, who are fully integrated into our multidisciplinary department of Critical Care Medicine.
For fellows, educational activities have also shifted to an online format. Those activities that are not amenable to this change have been canceled.
“As a group, we have had to stop our traditional weekly NCC education…ended our general critical care based lecture series and most unfortunately really lost out on maintaining the most important part of training ‘fellowship’ and being able to actually see and work with one another in person as of late,” said Matt Jaffe, University of Maryland.
Rather than concern for the lack of dedicated didactics, fellows' larger concern was decreased social interaction with their co-fellows.
“A major part of fellowship is the camaraderie that you develop with your colleague tackling a very specific interest within the world of neurology and…those friendships/mental partnerships are an important aspect of learning as a fellow,” said Kiruba Dharaneeswaran, University of Pennsylvania.
Many noted that their departments were otherwise working to sustain their educational mission, finding new and innovative ways to implement educational initiatives.
“We have also been assigned task forces such as the education task force… to keep up with literature and disseminate relevant practice guidelines,” Dharaneeswaran said.
Most institutions have leveraged their neurocritical care fellows as backup for other ICUs throughout the hospital. Almost all fellows that we interviewed endorsed involvement in a newly formed jeopardy systems, comingled with other ICU fellows. Paralleling the cancelation of elective surgeries, clinical electives for fellows have, in many cases, been canceled to minimize potential exposure of off-service fellows in order to bolster these reserves. In extreme cases, some neuro ICUs are reducing day-to-day coverage.
“For our fellowship, we have tried to work with the minimally effective staff in order to have a larger backup call pool and cancelled any other off service (SICU, MICU) fellow electives…elective neurosurgical cases are cancelled,” said Kassi Kronfield, Stanford.
Perhaps most significantly, both fellows and attendings are now finding themselves practicing outside the explicit domain of neurocritical care. Many neuro ICUs have converted to COVID-specific units or are now accepting more MICU/SICU patients as other units have made this transition.
Regardless of logistics, those interviewed almost universally endorsed significant changes to the patient populations for which they are now caring.
“The neuro ICU [has been] converted entirely to a coronavirus patient ICU, staffed by our team during the day and at night with medicine residents or fellows (as usually we work home call at that site)…we still have coronavirus patients coming to us and are expected to continue to take MICU and SICU patients while the coronavirus patients are cohorted. Numbers are rapidly increasing, so the hospital is in the process of converting the ORs and a separate floor to negative pressure ICU beds. In the meantime, all elective surgeries have been stopped, as have non-urgent elective admissions. Our neurosurgeons are stepping up to help staff the unit while they have less surgical work to do. Transfers are limited to patients that require advanced neurological care,” said Hannah Kirsch, Cornell/Columbia.
“People are being asked to play new roles: NeuroICU fellows will likely be running the neurocritical care units along with the attending, with limited APP/residents support as they may be deployed elsewhere. We might also be called upon to help cover the CVICU (ECMO/LVAD patients) and the COVID units,” said Pouya Ameli, Emory.
Even in the midst of this pandemic, patients invariably continue to have neurologic emergencies and many intensivists may feel more comfortable managing COVID-related ARDS than subarachnoid hemorrhage, for example. Neurointensivists, with their cross-disciplinary training, are therefore uniquely positioned to assist in our current crisis. As a younger specialty, the changes enacted here may impact our future roles, both in the way we train and how we practice.
As ICUs across the country change rapidly to accommodate the dramatic increase of COVID-19 patients in the hospital, the landscape of neurocritical care is evolving. Neurocritical care recruitment and education has fully entered the digital arena, with both being conducted solely online. Neurointensivists are more than ever being called upon to manage both neuro-emergencies and critically ill medicine and surgery patients, lending both their specific expertise to patients who continue to suffer from acute neurologic illness and answering a call to the frontlines of a battle heretofore unmatched.
It remains to be seen how many of these changes may persist, and the long-term effects of the COVID pandemic on our practice and the role of neurointensivists remain unclear. Despite this uncertainty, many have found meaning in the shared burden of these responsibilities.
“Many of us have not met yet, but after sharing experiences and fears and questions, the air around each of us felt a little warmer, the shock of what’s going on around the whole world a little softer…our NCS community adds to our resilience as we continue to move forward to serve our patients,” said Kassi Baird, Stanford.
While both medicine and neurocritical care seem at a crossroads, we and our interviewees hold the belief that we can emerge from this crisis stronger than ever, with a renewed conviction in our colleagues and in our place within critical care.