key: cord-259605-6qa17pfb
authors: Coleman, Julia R.; Burlew, Clay Cothren; Platnick, Kenneth B.; Campion, Eric; Pieracci, Fredric; Lawless, Ryan; Werner, Nicole; Coleman, Jamie; Hoehn, Melanie; Moore, Ernest E.; Cohen, Mitchell J.
title: Maintaining Trauma Care Access During the COVID-19 Pandemic: An Urban, Level-1 Trauma Center's Experience
date: 2020-05-01
journal: Ann Surg
DOI: 10.1097/sla.0000000000004001
sha: 
doc_id: 259605
cord_uid: 6qa17pfb

nan

Amidst the SARS-CoV-2 or "COVID-19" pandemic, the need for trauma care remains a critical public health responsibility. Anticipating augmentation of social determinants of violence, "end stage" presentations of surgical pathologies from delayed care, and demands on surgeons and surgical intensivists, readiness, adaptability, and leadership in trauma centers are paramount. This Surgical Perspectives centers around an urban, Level-1 trauma center's experience in meeting the challenge to maintain trauma care access and capability during the COVID-19 pandemic.

College of Surgeons (ACS)-and Colorado state-verified Level-1 trauma center. The Ernest E.

Moore Shock Trauma Center at Denver Health is one of the world's leading trauma centers, providing care to 18,000 trauma patients annually. DHMC is dedicated to maintaining a state of readiness, including access to the operating room (OR), intensive care unit (ICU), and the full complement of trauma center resources. Although surgical patient volume has decreased slightly in the past month with "shelter in place" ordinances, our demands remain high ( Figure 1 ).

Know your capability and capacity, and reorganize patient housing accordingly. In order to best allocate resources, preparedness and proactive strategy are vital. This requires knowing surge capability and capacity and ensuring that trauma resources are protected and preserved. Anticipating maximum capacity during the pandemic and ensuring mitigation of "in-house" disease spread mandates precise attention to patient distribution within the hospital. As we increased our ICU capacity for COVID-19 patients, we dedicated the surgical Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. ICU (SICU) to be the "clean" ICU for all trauma and surgical patients and COVID-19 negative MICU patients. In order to accomplish this, we re-organized patients based on COVID-19 risk stratification: "baseline" community risk (absence of recent fever, cough, and shortness of breath and no clinical or radiographic concern for COVID-19), "intermediate" risk (evidence of respiratory illness as suggested clinically and/or radiographically or patient from a skilled nursing or long-term care facility), and "high" risk (fever, cough, shortness of breath, and/or other concerning clinical or radiographic findings). After stratifying risk, a patient is directed to an appropriate initial location in the hospital: baseline risk to "clean" ICU or floor, intermediate risk to MICU or "COVID-19 floor" for rule out, and high risk or confirmed COVID-19 to MICU or "COVID-19 floor." Ultimately, this strategy of patient allocation ensures that at all times, there is an ICU free of known COVID-19 patients, and most importantly, we ensure capacity to always run a trauma center.

Have processes in place to augment and cohort personnel. After COVID-19 was identified in Colorado, DHMC promptly transitioned all clinic appointments to virtual telehealth, except for those which mandate in-person evaluation. This clinic is handled by advanced practice providers, overseen by a faculty surgeon, who work separately from the inpatient surgical team. In order to avoid the potential for COVID-19 spread decimating the workforce, we also expeditiously restructured our inpatient staff teams, at a faculty and resident level, to create two core cohorts of personnel with staggered shifts. Our current teams include trauma, emergency general surgery, and SICU, with a staggered "home cohort" on call and available if any provider becomes ill or demand increases. During our morning report and ICU rounds, all providers connect via virtual meeting software. and provide situational awareness on patient load and resource availability. Electronic medical record also facilitates timely data sharing, with "COVID-19" dashboards which collate the number of resulted and pending COVID-19 tests and the number of used and available ICU beds. These collated data inform implementation of each level of the surge plan, as well as trigger requests for additional resources.

Identify centralized leadership through existing national organizations. Urban, Level-1 trauma centers are uniquely poised to be "command centers" for trauma care. It is essential trauma centers reach out to regional institutions by way of Trauma Medical Directors (TMDs) and Trauma Program Managers (TPMs) to provide resources and expertise, ensuring regional trauma center capacity is preserved. This is best done by helping other trauma centers identify patients requiring transfer to high level of care and patients with potentially nonsurvivable injuries, as well as letting them know availability to receive transfers and/or consultations through telehealth platforms.

Continue best practices of trauma care, with extra precautions. Operationally, for the safety of personnel, all trauma patients should be considered infected with COVID-19 until proven otherwise. As such, strict use of personal protective equipment (PPE) should be worn by all personnel for trauma activations. If a history or current symptoms of COVID-19 exist, a face mask should be placed on the patient immediately. Additionally, in order to identify potential COVID-19 infections and allocate patient placement, for all trauma patients who are to be admitted and we are unable to obtain history, we obtain a chest computed tomography and then test for COVID-19 accordingly(1).

When it comes to personnel, less is more. It is the responsibility of the trauma team to minimize personnel in the trauma bay. Our current process is to have an emergency medicine Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

provider present for airway and initial rapid assessment, a trauma surgery chief resident present for procedures and secondary exam, and a nurse for venipuncture and medications in the room; these personnel are overseen by the trauma surgeon attending. The remaining team remains behind closed glass doors (trauma bay becomes a negative pressure room) in a standing area. The trauma surgeon attending presence facilitates rapid assessment and activation of the remainder of the team. Additionally, immediate response of trauma attending surgeon at all levels of alerts has increased quick triage and assessment of the need for additional personnel and resources.

Given aerosolization of the COVID-19 by respiratory tract violation (2), it is crucial that trauma teams carefully consider emergency department thoracotomy (EDT), intubation, and tube thoracostomy. If a patient requires intubation or tube thoracostomy, only one provider is in the room and with appropriate PPE (assuming COVID-19 infection until proven otherwise). With respect to EDT, in the setting of blunt traumatic arrest, we maximize use of resuscitative endovascular balloon occlusion of the aorta (REBOA) when deemed clinically equivalent to EDT.

While our massive transfusion criteria remain unchanged, in anticipation of blood shortages, we have adopted restrictive transfusion strategies in the ICU, anticipating potential preferential resuscitation with crystalloid and lowering our threshold for vascular surgery or embolization. We also proactively stockpiled topical hemostatic agents and other Figure 1 . Ongoing trauma center demands during COVID-19 pandemic. Blue represents percent of volume compared to prepandemic monthly average.

The indispensable role of chest CT in the detection of coronavirus disease 2019 (COVID-19)

SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients

Intubation of SARS patients: infection and perspectives of healthcare workers

Studies on the transmission of viral disease via the CO2 laser plume and ejecta

Resources for Smoke & Gas Evacuation During Open, Laparoscopic, and Endoscopic Procedures

Canadian Association of General Surgeons. Statement from the CAGS MIS Committee re: Laparoscopy and the risk of aerosolization

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