key: cord-315424-i3nnennw authors: Willer, Brittany L.; Thung, Arlyne K.; Corridore, Marco; D’Mello, Ajay J.; Schloss, Brian S.; Malhotra, Prashant S.; Walz, Patrick C.; Elmaraghy, Charles A.; Tobias, Joseph D.; Jatana, Kris R.; Raman, Vidya T. title: The otolaryngologist’s and anesthesiologist’s collaborative role in a pandemic: a large quaternary pediatric center’s experience with COVID-19 preparation and simulation date: 2020-06-10 journal: Int J Pediatr Otorhinolaryngol DOI: 10.1016/j.ijporl.2020.110174 sha: doc_id: 315424 cord_uid: i3nnennw There has been a rapid global spread of a novel coronavirus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which originated in Wuhan China in late 2019. A serious threat of nosocomial spread exists and as such, there is a critical necessity for well-planned and rehearsed processes during the care of the COVID-19 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be intimately familiar with strategies to mitigate the high-risk periods of viral contamination that are posed to the environment and healthcare personnel during tracheal intubation and extubation procedures. Since both the pediatric otolaryngologist and anesthesiologist are directly involved in emergency airway interventions, both specialties impact the safety of caring for COVID-19 patients and are a part of overall hospital pandemic preparedness. We describe our institutional approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital including operating room management and remote airway management. We outline our processes for the safe and effective care of these patients with emphasis on simulation and pathways necessary to protect healthcare workers and other personnel from exposure while still providing safe, effective, and rapid care. As of June 1, 2020, the rapid global spread of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), originating in Wuhan China, has led to more than 6,000,000 confirmed cases of COVID-19 since its identification in late 2019 [1] . With over 370,000 deaths attributed to the virus, its mortality rate is estimated between 3 and 6% [2] . The majority of COVID-19 related deaths occur in individuals ≥ 60 years of age [3] . More than 23% have at least one comorbid condition, with hypertension being the most common (12.8%) followed by diabetes mellitus (5.3%) [4] . Pediatric patients are susceptible to SARS-CoV-2 infection, but their infection rate is debated. Initially, China reported that only 2.4% of the confirmed and suspected cases of COVID-19 were in patients ≤ 19 years of age. However, a subsequent report from a single large city in southern China found that the proportion of pediatric cases increased from 2% to 13% later in the outbreak [5] . Lu et al. using data collected from January 28 through February 26, 2020 from the Wuhan Children's Hospital reported that 12.3% of children, who were either symptomatic or asymptomatic with known contact to persons having confirmed or suspected COVID-19, tested positive for SARS-CoV-2 [6] . Symptom severity does appear to be milder in most pediatric cases as compared to adult cases [5] . In a large study from China, only 5.6% of children infected with SARS-CoV-2 experienced severe disease, as defined by hypoxemia, and 0.6% experienced respiratory or multiorgan failure or acute respiratory distress syndrome (ARDS) [7] . However, the impact of pediatric comorbidities on the severity of COVID-19 disease is still largely unknown. In a Zhongnan hospital at the Wuhan University, 29% of COVID-19 cases were medical staff and 12.3% of cases were patients who contracted SARS-CoV-2 during hospitalization for other reasons [8] . Therefore, given the serious threat of nosocomial spread, there is a critical necessity for well-planned and rehearsed processes during the care of the SARS-CoV-2 positive and suspected patient to minimize transmission and risk to healthcare providers and other patients. This will require multidisciplinary in situ simulations and 'walk-throughs,' and hospital-wide participation to ensure a consistent approach. When emergency airway interventions are performed by pediatric otolaryngologists, the efficiency of each step is critical to best patient outcomes. The pediatric otolaryngologist and anesthesiologist will encounter the COVID-19 patient in a variety of clinical settings (perioperative/operative, intensive care unit, emergency department, and radiology suite) and situations (emergent airway management, urgent or emergent surgical intervention, diagnostic or interventional radiology, and critical care resuscitation). The pediatric otolaryngologist's and anesthesiologist's role in the COVID-19 patient's care is often occurring within an urgent or emergent context where an increased risk of contamination and therefore threat to public health exists. Because of the aerosolization inherent in airway management, the pediatric otolaryngologist and anesthesiologist should be welleducated in and familiar with strategies to mitigate these high risk periods of viral contamination that are posed to the environment and healthcare personnel during endotracheal intubation and extubation procedures [9] . This places the pediatric otolaryngologist and anesthesiologist in a position to be able to dramatically impact and improve the safety of themselves and those caring for these patients. By assisting other disciplines in the same, these consultants are uniquely equipped to lead hospital pandemic preparedness for the COVID-19 patient. We describe our approach to COVID-19 perioperative pandemic planning at a large quaternary pediatric hospital. Task Force. This Task Force divided further into specific teams: Resource Team, tasked with researching and disseminating accurate and up-to-date COVID-19 information. Airway Management Team, in collaboration with otolaryngology, tasked with innovating and protocolizing airway management strategies to minimize aerosolization and environmental contamination. Operating room (OR) Logistics Team, tasked with delineating workflow changes and navigating interdepartmental processes. Simulation Team, tasked with developing simulations for educating and preparing staff members on new processes. • Determine potential for difficult airway (request pediatric otolaryngology presence and initiate COVID-19 Potential Difficult Airway Protocol). • Designate trained PPE Donning/Doffing observer. • Confirm contact person for consent (phone consent expected prior to patient transport to minimize contamination). • Discuss anticipated transportation route (all patients to enter OR directly). • Surgical medications anticipated. o Anesthesia administered (eg. antibiotics, steroids, osmotic diuretics, antiepileptic agents) o Nursing administered (eg. local anesthetic agents, irrigation solutions) • Preoperative laboratory status. • Blood product needs and availability. • Special surgical equipment. • Anticipated patient disposition following surgery. The anesthesia, surgical, and nursing teams then proceeded with the simulated case, incorporating the COVID-19 measures each team had already prepared. During the course of the in-situ simulation, questions in management of the COVID-19 patient and environment were raised at the time of the simulation and addressed with input from the various stakeholders. As a result of this initial perioperative simulation, a perioperative COVID-19 protocol was developed, and an overarching perioperative workflow established (Figure 1 ). The perioperative simulation was then re-created with the nursing and surgical leaders for each surgical subspecialty. Emergent Airway Management: To date, the need for invasive or emergency airway interventions in SARS-CoV-2 infected patients has remained low as it has been reported that only 0.6% of pediatric patients with SARS-CoV-2 infection experience respiratory or multiorgan failure [7] . Yet, it is common for children to present to the emergency department (ED) and ICU with respiratory distress, whether related to viral infections or other etiologies. In such In our institution, the pediatric anesthesiology and/or otolaryngology departments (depending on clinical situation) serve as back-up for emergency airway management for the ED and ICUs. During the COVID-19 pandemic, given that there are now added precautions that need to be taken prior to managing an airway, it was important that the ED, ICUs, otolaryngology, and anesthesiology departments align their goals and expectations, but also appreciate the different challenges each unit presents in comparison to the controlled environment of the operating room. For example, in the operating room, the goal of airway management was to decrease environmental contamination so that the rest of the anesthetic care and surgical intervention could proceed under relatively clean conditions. While the patient is in the ED or ICU, multiple interventions may be performed prior to endotracheal intubation, such as aerosol treatments or respiratory assistance with non-invasive ventilation, which are all considered AGPs. From the ED or ICU perspective, everything about the patient encounter is high risk for the health care worker. We aimed to augment the existing airway management strategies and protocols with high-value infection control related addenda. In order to create a universal guideline that would be useful in environments as different as the OR, ED, and ICUs we focused on two core principles: 1. Minimizing contamination risk. 2. Defining the pathways for escalating the expertise for airway management. Toward the first goal for a universal guideline-minimizing contamination risk-the following points were added to each department's COVID-19 intubation protocols: • Donning and doffing areas will be clearly marked. • Intubation team will wear head coverings, such as the bouffant (common to the OR, but not routinely used in the ICU and ED). • Intubation team will double glove. • Non-essential staff members will leave the room during intubation. • Individual roles will be clearly delineated prior to beginning airway management. • Trainees will not be allowed to be the primary person managing the airway. • Viral filters will be used after intubation and during transport. • Inadvertent contamination from fresh oxygen flow through Ambu bags will be minimized by using lowest possible flow. • Inadvertent contamination from airway equipment will be minimized by ensuring strict attention to processes. • Videolaryngoscopy will be used as a first-line technique. • Intubation team will be dismissed immediately after the airway is secure for doffing following airway management. The second aspect for a universal guideline was to offer guidance for when and how to alert the otolaryngology and/or anesthesiology staff for assistance ( Figure 2 ). An emphasis was placed on early communication with these services to afford sufficient time for resource mobilization. The following guidelines were developed as pathways for escalating airway expertise in COVID-19 patients: Once the anesthesiology team arrives, they assume all airway responsibilities and determine who remains in the room during endotracheal intubation. This represents a transition from our previous practice of allowing advanced trainees in the ED or ICU to manage the airway under the anesthesiologist's guidance. To prepare for this, the anesthesiology department created a special emergency bag containing PPE and cleaning equipment, advanced airway equipment for use outside the operating room suites, and induction medication. This allowed the anesthesiology team to be self-sufficient and work in a manner more consistent with our workflow in the operating room. The literature contains a paucity of information describing the collaboration of the pediatric otolaryngologist and anesthesiologist for pandemic airway preparedness. The COVID-19 pandemic is a public health crisis in which an estimated 19,481 individuals will require endotracheal intubation during peak demand in the United States [13] . In order to mitigate contamination risk, COVID-19 patients should be intubated by the most skilled providers, underscoring the important role the pediatric otolaryngologist and anesthesiologist. In situ simulation is a vital aspect for disaster preparation, as it has been shown to improve clinical skills, teamwork, patient safety, and reliability in high-risk and high-stress environments [14, 15] . In our COVID-19 preparations, interdisciplinary cooperation was helpful for identifying problems that each individual department had not previously recognized and addressed. Each simulation and 'walk-through' exercise improved communication, workflow, and response times. As a result of these simulations, potential barriers, omissions, and issues were identified. These resulted in modifications to existing protocols which aimed to add infection control-specific principles and facilitate patient care. Barriers did exist to the development and implementation of these protocols and simulations. With the initial confinement of SARS-Co-V-2 to international locations, the impact the virus would have within our community if spread occurred was difficult to ascertain. Given that the potential pandemic nature of SARS-Co-V-2 was not recognized on a national level early, large-scale preparations for the pandemic were delayed until COVID-19 cases were already present within the community. At that point, a critical time constraint became evident, which demanded that we mobilize resources quickly to develop these pathways. One key factor in being able to do this was that we quickly stopped all elective surgical cases in institutions which provided the necessary time and manpower requirements to develop these strategies. Given that the initial reports from China indicated low pediatric infection rates, it is possible that the public health impact COVID-19 would have within a pediatric hospital was underestimated. It is possible that as a result, some have questioned the need to adopt changes in pediatric practices related to the pandemic [5] . During a pandemic, there are particular populations that may not manifest symptoms related to the disease but who unwittingly pose as a major public health threat by serving as a vector for spread [16, 17] . The asymptomatic carrier state is particularly dangerous with regards to nosocomial spread of infection as healthcare workers may not employ full COVID-19 precautions in caring for the seemingly uninfected patient. AGPs, such as endotracheal intubation and extubation, which under other circumstances appear routine, become high-risk for disease transmission to healthcare providers. Therefore, during a pandemic situation, it is imperative to treat all populations, with the same screening procedures and precautions. Fortunately, the COVID-19 related case burden in our center has been low to this point, in part because of an aggressive state government that enacted very early school closures and 'stay-at-home' orders in conjunction with federal social distancing guidelines. In a 21 st century global economy where the air travel is a major facilitator in international disease distribution, the spread of novel pathogens leading to a pandemic of comparable proportion to COVID-19 is not likely to be a singular isolated event [18] . It is imperative, therefore, that going forward pediatric otolaryngology and anesthesiology departments maintain this level of basic collaborative preparation for these situations. Coronavirus disease (COVID-2019) situation reports: Situation Report-133 Real estimates of mortality following COVID-19 infection CDC Covid-19 Response Team. Severe outcomes among patients with coronavirus disease (COVID-19) Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China COVID-19): Information for Pediatric Healthcare Providers SARS-CoV-2 Infection in children Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review COVID-19): interim infection prevention recommendations for patients suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management Recommendations for endotracheal intubation of COVID-19 patients Forecasting COVID-19 impact on hospital bed-days, ICU-days, ventilatordays and deaths by US state in the next 4 months. Institute for Health Metrics and Evaluation (IHME) Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore Role of in-situ simulation for training in healthcare: opportunities and challenges Presumed asymptomatic carrier transmission of COVID-19 Asymptomatic carrier state, acute respiratory disease, and pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2): Facts and myths The association between international and domestic air traffic and the coronavirus (COVID-19) outbreak We would like to thank the Nationwide Children's Hospital perioperative nursing staff and nursing leaders, Dr. Marc Michalsky of the General Surgery team, Dr. Mark Hall and Dr. Onsy Ayad of the Pediatric Intensive Care Unit team, and Dr. Berkeley L. Bennett of the Emergency Department team for their participation in our perioperative and hospital-wide simulations. We would especially like to thank our tireless department of anesthesiologists, fellows, and nurse anesthetists who helped make these large scale COVID-19 preparations a success.