key: cord-1043270-jprceyc7 authors: Aly, Sherif; Talutis, Stephanie D.; Richman, Aaron P.; Hess, Donald T.; McAneny, David; Tseng, Jennifer F.; Drake, F. Thurston title: The Boston Medical Center COVID-19 Procedure Team: Optimizing the Surgeon’s Role in Pandemic Care at a Safety Net Hospital date: 2020-06-04 journal: Surgery DOI: 10.1016/j.surg.2020.05.030 sha: 4605ac306aa9017563d7dc3f7b0351130a16ab41 doc_id: 1043270 cord_uid: jprceyc7 BACKGROUND: The COVID-19 pandemic has claimed many lives and strained the US health care system. At Boston Medical Center (BMC), a regional safety net hospital, the Department of Surgery created a dedicated, COVID-19 Procedure Team to ease the burden on other providers coping with the surge of infected patients. As restrictions on social distancing are lifted, health systems are bracing for additional surges in COVID-19 cases. Our objective is to quantify the volume and types of procedures performed, review outcomes, and highlight lessons for other institutions that may need to establish similar teams. STUDY DESIGN: Procedures were tracked prospectively along with patient demographics, immediate complications, and time from donning to doffing of the personal protective equipment (PPE). Retrospective chart review was conducted to obtain patient outcomes and delayed adverse events. We hypothesized that a dedicated, surgeon-led team would perform invasive bedside procedures expeditiously and with few complications. RESULTS: From March 30 to April 30, 2020, there were 1,196 COVID-19 admissions. The Procedure Team performed 272 procedures on 125 patients, including placement of 135 arterial catheters, 107 central venous catheters, 25 hemodialysis catheters, and 4 thoracostomy tubes. Specific to central venous access, the average procedural time was 47 minutes, and the rate of immediate complications was 1.5%, including 1 arterial cannulation and 1 pneumothorax. CONCLUSIONS: Procedural complication rate was less than rates reported in the literature. The team saved approximately 192 hours of work that could be re-directed to other patient care needs. In times of crisis, redeployment of surgeons (who arguably have the most procedural experience) into procedural teams is a practical approach to optimize outcomes and preserve resources. Massachusetts ranks third-highest in total cases of Coronavirus disease 2019 (COVID-19) in the US 1-3 . As a safety net hospital, Boston Medical Center (BMC) cares for our city's most vulnerable patients, and as expected, we have been impacted disproportionately. During early April of 2020, 7 of 10 patients admitted were ill from COVID-19, many of whom required care in the intensive care unit (ICU) 4, 5 . After cancelling all non-urgent operations, the Department of Surgery restructured and consolidated our surgical services. These measures were intended to preserve hospital capacity for the anticipated surge of patients, to conserve PPE, to protect house officers and faculty, and to maintain a reserve of healthy personnel as other frontline colleagues potentially fell ill. A dedicated Procedure Team was created and still performs invasive, bedside procedures on all COVID-19 patients. Our goal was to perform these procedures expeditiously with high success rates, decreasing adverse outcomes, limiting clinician exposure to COVID-19, and decreasing use of valuable PPE, often in short supply. This short term follow-up study has 3 aims: [1] describe the number and types of procedures performed by the Procedure Team, [2] quantify and assess outcomes, and [3] extrapolate lessons for other institutions that may need to establish a similar team in a short timeframe. These data add to the COVID-19 literature by describing a mechanism through which surgeons can effectively use their skills in the current pandemic-particularly as hospitals brace for a possible second COVID-19 surge when restrictions on social distancing are lifted-and potentially in future acute disruptions to health care systems and hospitals. The COVID Procedure Team is comprised of an attending surgeon and two senior surgery residents. As the number of COVID-19 cases increased in the hospital, surgeons in the Section of Trauma and Acute Care Surgery were deployed fulltime to the ICUs, and the non-critical care surgeons now staff 2 inpatient surgical teams. The "non-admitting" surgical team (alternating daily) is the Procedure Team for that day and is available 24 hours per day. Training sessions for ultrasonographically-guided central venous catheter (CVC) insertion were led by a critical care surgeon and conducted via web-conferencing and in the BMC Simulation Center. A dedicated supplies cart and portable ultrasound machine were utilized. Residents on the team were responsible for restocking the cart. The team tracked prospectively all procedures in a database for purposes of quality control and resource planning. Our Institutional Review Board approved this retrospective chart review for all patients who underwent procedures during the team's first month (3/30/2020 -4/30/2020), including demographics, co-morbid conditions, and hospitalization details. Adverse events that occurred after catheter placement, referred to as "delayed events," were captured, including catheter dislodgement, catheter-associated infection, and catheter thrombosis. Catheter-associated infection was defined according to standard guidelines of the Centers for Disease Control (CDC) 6 . Association of complications and PGY level (PGY3 vs. PGY4 vs. PGY5) was assessed using Analysis of Variance (ANOVA). Over the one month study period, 1,196 patients required hospitalization at BMC for confirmed or suspected COVID-19, accounting for more than 75% of the daily admissions during Boston's COVID-19 "peak." About 10% of these patients (n=125) required 272 invasive bedside procedures by the Procedure Team. Demographics and co-morbid conditions are detailed in Table 1 . The mean number of procedures per patient was 2.2, with 91% of patients undergoing more than one procedure. A total of 135 arterial catheters, 107 CVCs, 25 hemodialysis catheters, and 4 thoracostomy tubes were placed. Arterial catheters were placed generally in radial arteries (92%), and to a lesser extent (6%) the femoral arteries. Axillary arterial catheters were placed in specific situations when extensive vascular interventions precluded use of the femoral artery. CVCs were placed mostly in the internal jugular (IJ) vein (55%), followed by subclavian (37%) and femoral (8%) veins. Regarding hemodialysis catheters, 60% were placed in the IJ veins and 40% in femoral veins. Thoracostomy tubes were placed in 4 patients for pneumothoraces (one iatrogenic). (Table 2) The rate of immediate complications among the placement of all CVCs and hemodialysis catheters was 1.5%. One patient developed a pneumothorax after subclavian CVC placement. Another patient required emergency vascular repair after a through-and- Hospitalization details are included in Table 3 . COVID-19 has challenged the United States' health care system and, in many ways, overwhelmed its resources. Our institution reorganized to maximize capacity for COVID-19 patients in one of the hardest-hit cities in the United States. Among other efforts, the BMC Department of Surgery created a COVID-19 Procedure Team, which was formally integrated into our institutional response to the pandemic. The BMC COVID-19 Procedure Team performed 272 procedures in 125 patients in one month. This required approximately 192 hours of work (equivalent to 16, twelve-hour shifts). These were extremely ill patients as evidenced by the 93% ICU admission rate and 87% intubation rate (44% ventilated prone). The Procedure Team decreased clinician exposure and promoted expertise with donning and doffing of PPE, conserving those supplies and minimizing provider infections 7 . The procedural complication rate for central venous and hemodialysis catheters was 1.5%, which is substantially less than rates reported in the literature (3-10%) 8 . There was a single iatrogenic pneumothorax (0.9% of IJ and subclavian central venous and hemodialysis catheters), again less compared to rates in the literature (1.0-6.6%) 9 , and a single arterial cannulation (0.8% of all central venous and hemodialysis catheters), similar to the rates of 0.1-1% reported in the literature [10] [11] [12] . The IJ veins were particularly favored for patients who were morbidly obese, have chronic kidney disease (to avoid central venous stenosis of the subclavian or brachiocephalic veins), or are receiving therapeutic anticoagulation. Subclavian CVCs were performed relatively frequently (37%) and became our preferred approach, because they saved time and prevented potential cross-contamination via the ultrasound machine. Subclavian access is also valuable in the setting of tracheostomies that might contaminate an IJ vein cannulation site. Whenever possible, the right IJ vein is preserved for hemodialysis catheters. Initially, the thrombosis rate of arterial catheters was relatively high (22%), with many patients requiring multiple replacements. This is likely related to the thrombogenic nature of COVID-19 infection [13] [14] [15] . In response, we implemented continuous infusions of dilute heparin (2 units/mL, infused at a rate of 3 mL/h) as supported by studies demonstrating prolonged catheter patency and lesser rates of thrombosis compared to normal saline [16] [17] [18] . Several lessons have been gleaned from this experience. Departmental restructuring was necessary to produce the manpower required to consistently staff the Procedure Team. This process required engagement by all non-Trauma attending surgeons, which was easily accomplished in our Department. These procedures were not considered teaching cases, and we limited their performance to senior level residents, thus limiting provider exposure and conserving PPE. The team utilized its own equipment and supplies without relying upon the ICU stockrooms, which allowed for uniformity of practice and minimized the need for entering and exiting the room during procedures. (Procedure carts remained outside the room.) We found that use of subclavian CVCs, unless contraindicated, decreased time in patient rooms. Safety was not compromised with no increase in complication rates. This study has limitations. The study period was limited to one month, preventing us from tracking long term outcomes. Additionally, as a single institution study, the results may not be applicable to other centers. Nevertheless, our data support the practicality and value of rapidly implementing a surgeon-led, invasive procedure team during a pandemic when elective operations are halted. To our knowledge, there is only one other published report describing the implementation of such a team in response to the COVID-19 pandemic 19 . The data reported here, including procedural volume, time savings, and short term outcomes, provide additional support for the feasibility and safety of this type of endeavor. As communities begin to lift measures of social distancing, health care institutions are bracing for a potential second surge of COVID-19 infections, and future acute disruptions to our usual care processes must be anticipated in this globalized world. versus normal saline in the maintenance of invasive arterial lines in intensive care. Intensive Care Med Exp. 2015;3(S1): The team saved approximately 192 hours of work that could be re-directed to other patient care needs. In times of crisis, redeployment of surgeons (who arguably have the most procedural reports Coronavirus COVID-19) | National Institutes of Health (NIH) Here's a list of coronavirus cases in Massachusetts by hospital -The Boston Globe The heart of the coronavirus storm -The Boston Globe Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-Central Line Associated Bloodstream Infection) Personal Protective Equipment and Covid-19. Ingelfinger JR Central Line Catheters and Associated Complications: A Review Pneumothorax as a complication of central venous catheter insertion Vascular complications of central venous catheter placement: Evidencebased methods for prevention and treatment Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm Complications of Central Venous Catheterization Thromboinflammation and the hypercoagulability of COVID-19 Hypercoagulability of COVID-19 patients in Intensive Care Unit. A Report of Thromboelastography Findings and other Parameters of Hemostasis Critically Ill COVID-19 Infected Patients Exhibit Increased Clot Waveform Analysis Parameters Consistent with Hypercoagulability Finding a solution: Heparinised saline versus normal saline in the maintenance of invasive arterial lines in intensive care The authors have no related conflicts of interest to declare. TOC Statement-20200796 Formation of a surgeon-run, COVID-19 Procedure Team eased the workload of providing medical care to COVID-19 patients, decreased exposures to COVID-19, conserved personal protective equipment, and allowed for expeditious bedside procedures at lesser-thanexpected rates of complications. The importance of this study is that it may serve as a guide for surgeons in future acute disruptions to the health care system and provides data on realistic anticipated outcomes.