key: cord-0807352-6lfdfm6a authors: Shaparin, Naum; Mann, Glenn E.; Streiff, Agathe; Kiyatkin, Michael E.; Choice, Curtis; Ramachandran, Sujatha; Delphin, Ellise; Adams, David C. title: Adaptation and Restructuring of an Academic Anesthesiology Department during the COVID-19 Pandemic in New York City: Challenges and Lessons Learned date: 2020-12-10 journal: Best Pract Res Clin Anaesthesiol DOI: 10.1016/j.bpa.2020.12.010 sha: 3eb34f1e63620b40d9fdf78a2b13f04e647edc1c doc_id: 807352 cord_uid: 6lfdfm6a The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff’s expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU) and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single-center’s experiences. On March 11, 2020 , the World Health Organization (WHO) declared the Coronavirus disease 2019 (COVID-19) outbreak to be a global pandemic. 1 Soon after, New York City experienced an exponential increase in COVID-19 hospitalizations. As the largest academic medical center in the Bronx, Montefiore Medical Center faced the greatest surge in hospital admissions in its history. This event was complicated by nationwide shortages in personal protective equipment (PPE) 2,3 , mechanical ventilators and advanced monitoring-capable beds. In response to a March 23, 2020 emergency order by the governor of New York State, Andrew Cuomo, mandating an increase in hospital bed capacity by 50% 4 , our institution rapidly restructured and mobilized resources, and employed novel solutions. As the COVID-19 surge became inevitable and threatened to overwhelm healthcare resources, the U.S. Surgeon General recommended a suspension of elective surgery and clinic visits on March 22, 2020. 5 This recommendation was endorsed by the American Society of Anesthesiologists, Ambulatory Surgery Center Association, and American College of Surgeons, and it was soon mandated by state and local authorities. [6] [7] [8] In our institution, elective surgeries were suspended starting March 19, 2020. While Montefiore Medical Center typically maintains a 106 intensive care unit (ICU) bed capacity, at the peak of the COVID-19 outbreak, capacity was more than doubled to 258 ICU beds, with over 90% occupied by SARS-CoV-2 positive patients. Non-clinical spaces such as conference halls were converted into patient care areas. Ratios of patient to providers varied across the several existing ICUs, newly formed ICUs and provider types. In the department of anesthesiology, staff were deployed to the COVID-19 ICUs from March 30 to May 18, 2020, with all members of the department returning from ICU deployments by July 1, 2020. Elective J o u r n a l P r e -p r o o f surgical cases resumed in our institution on June 10, 2020, with only emergent or urgent cases being performed throughout the surge period. In this article, we share the transformative experience of our anesthesiology department and the valuable lessons we learned during the COVID-19 pandemic in New York City (Table 1 , 2). The pre-COVID-19 anesthesiology staffing schedule consisted of non-call daytime assignments, late calls, overnight general OR, subspecialty home calls and obstetric anesthesiology calls. During the pandemic, all clinical assignments were converted into 12-hour in-hospital clinical shifts or 24-hour subspecialty pager call. Non-clinical assignments, vacation, and meeting time were suspended temporarily in anticipation of the increased personnel needs of the COVID-19 response. Attending anesthesiologists were assigned three to four shifts per week. Personal preferences such as night shifts, weekend shifts, or clustered assignments were accommodated when possible. These 12-hour in-hospital shifts were decided upon at the direction of the department leadership including the Chair. This model provided faculty with an equitable and standardized schedule, maintained staffing balances in the OR and ICUs and allowed for built-in days "off", which were separate from post-call days. Faculty were aware that they could be deployed during these days in the event of staff illness or absence. This time off was also created so that faculty could attend to their families and their own well-being. Changes in frequency of public transportation during the pandemic did not impact staff punctuality. 24-hour subspecialty home calls in cardiothoracic, neuroanesthesia, pediatric, and solid organ transplantation were maintained for emergent cases. Subspecialists were off duty post-call. When not on subspecialty call, subspecialists maintained a 12-hour shift schedule in the OR or the newly formed ICUs as above. Staffing of the ORs and non-OR anesthetizing locations for emergency cases was maintained. OR faculty were available in-house for emergency airway management. Similar to the pre-pandemic era, pediatric anesthesiologists screened and staffed cases in non-operating room anesthetizing locations such as diagnostic imaging. Anesthesiology faculty roles in the ICUs varied depending on their skills and assigned ICU. For example, anesthesiology faculty were the primary intensivists in one of the newly formed OR-ICUs, which consisted of six ORs converted into ICU-level COVID-19 patient beds. Cardiac anesthesiologists were the primary intensivists staffing the Ambulatory Surgery Unit (ASU) converted into a COVID-ICU in our quaternary care center. In other newly formed ICUs, anesthesiology faculty held consultant responsibilities such as airway and ventilator management, sedation, fluid administration, hemodynamic support, and placing patients in the prone position. Scheduling was maintained on SpinFusion, a web-based scheduling software program (SpinFusion, Inc, Denver, Colorado, United States). A manual schedule was generated for new assignments because the pre-pandemic automated process was a multi-step, complex algorithm 9 While this model has been championed by some 10 and is widely implemented throughout Europe, 11 it remains relatively unique in the United States. One of its many benefits is a pooling of resources across departments, allowing for efficient deployment of staff across critical care services. This centralized model proved ideal for the COVID-19 outbreak. Prior to receiving the first COVID-19 patient, staffing and unit surge plans were developed. Within a few weeks of the first COVID-19 admission, all ICU-trained anesthesiologists were deployed to 100% critical care duties. Within the anesthesiology department, ICU-trained anesthesiologists provided frequent didactics on COVID-19 and general ICU topics, and created patient care protocols. Critical care anesthesiologists were also readily accessible to non-ICU trained anesthesiologists. The Pain Center was closed in accordance with institutional and governmental policies. Pain physicians with recent OR experience were deployed to the general pool as described above. Pain physicians removed from the ORs were assigned other crucial roles such as transitioning the pain program to telemedicine and e-consults for inpatients. Pain physicians jointly certified in hospice care assisted the palliative care team with goals of care discussions. This additional staffing was significant during a time when palliative care services were overwhelmed. Since visitors were no longer allowed in the hospital, there was an urgent need to update patient families. J o u r n a l P r e -p r o o f Montefiore Medical Center is one of the largest graduate medical education (GME) sites in the United States. Anesthesiology residents were deployed by the central deployment office, which was established by the hospital administration at the beginning of the surge and functioned separately from the GME office. This central deployment office received updates regarding the creation of new COVID-19 ICUs. A majority of the CA-3 residents had already achieved the minimum required case numbers to graduate. Although this deployment did not impact their graduation requirements, it did shorten their clinical experience in the missed rotations. Anesthesiology residents and fellows staffed six newly formed ICUs in addition to the preexisting ICUs. The residents' experiences from their prior ICU rotations proved instrumental in educating non-ICU-trained bedside nurses and other multidisciplinary staff. In order to provide continuity of care and, to the extent possible, preserve vacation time that was previously granted, anesthesiology residents were assigned two weeks of ICU followed by a two-week rest period. Any vacations that were previously granted coincided with the two-week rest period. The residents were supervised by anesthesiology faculty and the Accreditation Council for Graduate Medical Education (ACGME) supervision and work hour rules were strictly followed. During one of the two rest weeks, residents were assigned one OR overnight call each, with the exception of residents on previously granted vacations. This unique schedule allowed for built-in quarantine time should a resident or fellow become ill. The cardiac, regional, pediatric anesthesiology and chronic pain fellows were placed on the same schedule as the residents. Residents staffed the labor and delivery floor along with the J o u r n a l P r e -p r o o f Residents and fellows were debriefed at the end of their assignments in the newly formed ICUs. Additionally, all residents were debriefed in small groups by a wellness expert. Following the debriefings, no major immediate changes in resident schedules or evaluative processes were made, however, resident feedback of the surge ICUs will be incorporated in future. More importantly, the debriefing sessions were an opportunity for residents to share their thoughts, emotional responses, and collective experiences of the deployments. The sessions allowed departmental leadership to express their gratitude for the high level of commitment and professionalism that was evident in the residents' performance. One significant obstacle to opening more intensive care environments at our institution was the availability of nurses, in particular, those with ICU training. CRNAs were deployed to assist the ICU consult services, emergency departments, and newly formed ICUs, which were primarily staffed by non-ICU trained bedside nurses. In the latter locations, they served as a nursing educator for the management of airways, ventilators, vasopressors, and resuscitation. The overwhelmingly positive feedback confirmed the significant roles CRNAs provided during this pandemic. Similarly to the anesthesiology attendings, scheduling was converted from SpinFusion to a manual process due to the need for overnight staffing and evolving clinical assignments. The department reached out to all members who were pregnant, over the age of 65, or had high-risk medical conditions to discuss their preference regarding direct clinical care during the pandemic, in which definitive risk factors, including short-and long-term sequelae on fetal outcomes, remain largely unknown. Members with personal concerns and need for accommodations with child care and sick family members were also encouraged to come forward. The number of affected staff -among anesthesiology attendings, residents, fellows, CRNAs, technicians, administrative staff -was a small percentage of the department, and they served in other capacities based on their skills. Attending anesthesiologists not assigned to clinical settings were assigned administrative responsibilities such as the creation of COVID-19related quality improvement and patient safety protocols along with existing committees (Fig. 1 ), management of a department pandemic resource website, case coordination, staff scheduling, sustaining didactics, and wellness efforts such as debriefings and sponsored meals. Outside of the department, staff members were deployed to our institution's occupational health services to assist the call center with the high volume of ill employees. Lastly, staff members were deployed to clinical roles without patient contact, such as pre-operative Telehealth assessments in preparation for resuming elective surgeries. The Hutchinson Metro Campus of Montefiore Medical Center, referred to as "the Hutch", is a standalone 16 OR ambulatory surgery center (ASC) that was converted into an inpatient COVID-19 facility with 14 ICU beds and 60 floor beds. Within one week, the ASC-ORs were repurposed for ICU patient care and the ASU and PACU areas received inpatients not requiring ICU level of care. 24-hour laboratory, radiology, nutritional, respiratory therapy, and critical care J o u r n a l P r e -p r o o f pharmacy services were established. The ASC-ICU medical team consisted of an attending anesthesiologist, residents, CRNAs and ASC nursing staff. Access to critical care consults via a centralized command center was provided. There were many inherent challenges in converting an ASC into an inpatient hospital facility. Staffing was one concern since this ASC previously operated from 6 am to midnight on The absence of hospital level laboratory services made the management of critically-ill patients difficult. Blood specimens were couriered to a nearby hospital while blood gas specimens were analyzed on point of care instruments. Many of the medications available in an ICU were not available in the ASC. Hemodialysis was also unavailable, necessitating an exclusion of patients with renal failure from transfer to the ASC-ICU. Due to these challenges and a decrease in patient volume, critical care services were consolidated to the main hospitals after six days, and the inpatient floors were closed five days thereafter. There were significant concerns among staff members for PPE that was on a nationwide shortage. 2, 3 The department and perioperative leadership explored various types of respirators to J o u r n a l P r e -p r o o f distribute to staff. Even in the earliest phases of the COVID surge, access to an adequate supply for providers was challenging. At the peak of the COVID surge, one disposable N-95 mask was distributed to OR personnel daily. Because of concerns about obtaining additional supplies, the initial rollout was envisioned to be two masks per week per personnel with reuse, but adequate supplies were procured and this rationing plan ultimately did not need to happen. Departmental Grand Rounds were preserved by converting the lecture hall format to entirely online sessions. The content, previously comprised of morbidity and mortality cases and topics of direct relevance to our anesthesiology practice, was revised to suit the current needs, such as wellness and self-care, COVID-19-related education, and updates in ICU management. Similarly, resident lectures were converted to an entirely online format. Due to the importance of social distancing and various locations of departmental members, this format for departmental meetings is expected to continue for the foreseeable future. but instead a different landscape. Compared to the rapid termination of elective procedures, reopening and resuming elective surgeries required a more complex, coordinated effort ( Table 2) . A core team consisting of the anesthesiology department chair, surgery department chair, and perioperative leadership was established to determine the process for resuming elective surgery. These recommendations were informed by society guidelines such as those of the American Society of Anesthesiologists, American College of Surgeons, Association of Perioperative Registered Nurses, and American Hospital Association, which released a Joint Statement on April 17, 2020 on the criteria for reopening of elective surgery. 13 In accordance with these guidelines, supplies of PPE, pre-procedural testing, ICU bed availability, and case prioritization were organized. The OR block schedule that existed prior to the pandemic was suspended to prioritize elective procedures based on urgency of intervention and risks of further delay to the patient. A tiered approach to reopening to previous full capacity was created in light of this goal. A percentage of ORs at each campus, ranging from one to six ORs, are maintained in a negative pressure environment for COVID-19 positive or untested patients. A negative SARS-CoV-2 test of less than 72 hours is required for all patients presenting for elective procedures. Nasopharyngeal swab polymerase chain reaction (PCR) tests are performed by licensed practical nurses (LPNs) across seven testing sites, including two drivethrough testing centers. Same day SARS-CoV-2 PCR testing with processing times of two hours is reserved for patients undergoing highly aerosolizing procedures such as bronchoscopy. Temperature screening is required for all individuals entering the facility. (Table 1) . We learned important lessons, demonstrated the value of clinical anesthesiology for a hospital system, and noted opportunities for improvement. The principal take home message for hospital systems that have confronted the COVID-19 pandemic is the importance of surge planning and preparation. These measures have long been appreciated and recommended in epidemics and disasters. 16, [17] [18] [19] Anesthesiologists are wellpositioned to be leaders in this planning whether or not they directly administer critical care services because they have extensive experience working with a multitude of clinical specialties across various hospital sites. In staff deployment, each individual's unique skillset must be considered. One model is to divide the anesthesiology workforce into three groups: a subset for elective and urgent OR procedures, a second subset of critical care intensivists involved in ICU staffing, and a third subset that deliver of out-of-OR non-ICU care such as obstetric anesthesia and pain management. 20 The authors recommend two additional groups: a fourth team for effective communication of resources and wellness, and a fifth group focused on maximizing research initiatives, quality and patient safety. In addition to scheduling clinical assignments that allow for illness and medical absences, it is vital to promote wellness amongst staff and trainees. The COVID-19 outbreak in New York J o u r n a l P r e -p r o o f City created tremendous stress amongst healthcare providers and support staff, with long-term effects anticipated. 21 Wellness initiatives should be implemented and resources must be provided. One simple example is our model for assigning anesthesiology residents to two-week blocks of ICU followed by a two-week rest period. Another important lesson is the immense value of critical care training in anesthesiology. At our institution, the anesthesiology intensivists took on leadership roles during the COVID-19 outbreak, providing expert patient care and hands-on assistance for staff deployed to the ICU. Moreover, we noted the importance of critical care in anesthesiology residency training. Residents and fellows seamlessly transitioned from their scheduled OR clinical rotations to become full-time critical care providers. They worked alongside non-intensivist attending anesthesiologists deployed to the ICU, combining workflow proficiency with clinical experience. Some have argued that the COVID-19 outbreak further highlights the importance of simulation for medical education. 22, 23 An editorial from 2010 argued for a greater focus on perioperative medicine with residents being required to select either a critical care or pain medicine six-month track in their final year of training followed by an optional, specialized 12-month fellowship. 24 Such a model, especially with a fast-track option, would enable trainees to graduate in five years with two years of subspecialty training. As the New York City area and our institution heal and return to normal activities, the humbling experiences from the initial surge should be remembered, evaluated, and shared. The lessons from our center highlight areas for improvement in anesthesiology practice, education, and organization. It is our duty to our patients and specialty to emerge from this tragedy better prepared for future challenges. • During the pandemic surge, the need to extend anesthesia critical care capacity while maintaining subspecialty availability for emergent operating room procedures were the primary drivers of staff scheduling. • In collaboration with the GME office and a newly formed staffing command center, a small core of anesthesiology trainees were assigned to OB rotations and emergent OR cases while the remainder were deployed to expanded critical care areas. • Trainee redeployment was based on level of training and experience and ensured compliance with ACGME duty hour regulations. • High risk staff, including those over 65 and pregnant, were given the option to continue clinical work or to be reassigned to vital administrative roles such as populating the staffing schedule, developing a departmental informational webpage, assisting with PPE supply management, and coordinating department-wide educational activities. • Communication was enhanced with the creation of a COVID-19 specific departmental website as well as twice weekly departmental virtual "town hall" meetings. • Using tools such as checklists and mock drills (simulation), departmental and institutional pandemic preparedness should be regularly evaluated to determine current readiness and identify knowledge or performance gaps that will inform future pandemic responses. • The potential value of additional resident critical care training needs to be studied to determine whether this would be beneficial in future scenarios in which anesthesiologists are emergently shifted to staff intensive care units. • The role and value of rapid dissemination of care pathways and treatment protocols through curation of digital media or other types of communication should be evaluated. • Using surveys, review of critical events, and patient outcomes, optimal staffing strategies for newly formed ICUs, including staff type, skills, and subspecialty needs should be evaluated. 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Microbes Infect Clinical Characteristics and Outcomes of Patients Undergoing Surgeries During the Incubation Period of COVID-19 Infection. EClinical Medicine Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective. American journal of respiratory and critical care medicine A Conceptual and Adaptable Approach to Hospital Preparedness for Acute Surge Events Due to Emerging Infectious Diseases Configuring ICUs in the COVID-19 Era SCCM COVID-19 Discussion Group: Society of Critical Care Medicine b9407194938d/Configuring-ICUs-in-the-COVID-19-Era-A-Collection Updated Reconfiguring the scope and practice of regional anesthesia in a pandemic: the COVID-19 perspective Supporting the Health Care Workforce During the COVID-19 Rapid training of healthcare staff for protected cardiopulmonary resuscitation in the COVID-19 pandemic. British journal of anaesthesia Simulation as a tool for assessing and evolving your current personal protective equipment: lessons learned during the coronavirus disease (COVID-19) pandemic The innovative anesthesiology curriculum: a challenge and hope for the future He has received research funding from Grunenthal and Heron therapeutics. For both authors None of the authors have any conflict of interests to disclose J o u r n a l P r e -p r o o f