Meeting Reviews

Friday Session III: COVID - Stories from the Front Lines

Reviewed by Kamie Yang, MD
Assistant Professor, Department of Pediatric Anesthesiology
University of Michigan, C.S. MOTT Children's Hospital

Dr. Yang

COVID in New York City
The COVID-19 surge in New York City peaked at the end of March 2020 with a staggering 15,000 patient hospitalizations per day.  COVID-19 deaths peaked a few weeks later during the second week of April with over 500 deaths per day.  Albert C. Yeung, MD is a pediatric anesthesiologist and Assistant Professor at New York-Presbyterian/Weill Cornell.  His institution is part of a major academic medical center composed of Columbia and Cornell Universities.  Together, the system receives over two million patient visits annually and has 2,600 beds over seven campuses. 

Prior to the COVID surge, Dr. Young’s home institution had a 116-bed critical care capacity.  At the peak of the COVID surge, his department successfully created 60 new COVID ICU beds in their ORs and PACUs that utilized anesthesia machines for ventilators.  To meet the needs of these newly created ICU beds, the physical structure of their ORs and PACUs had to be rapidly retrofitted.  At the same time, the clinical staffing roles of their entire department were reorganized. 

The general timeline of notable events during the COVID surge at New York-Presbyterian were as follows:

• March 1: First confirmed COVID-19 case in NYC.
• March 7: Governor Cuomo declares a State of Emergency.
• March 13: President Trump declares a State of National Emergency.
• March 14: First COVID-19 death in NYC.
• March 16: New York-Presbyterian postpones elective surgeries; departmental reorganization starts.
• March 22: Non-essential businesses close.
• March 24: FDA approves emergency use of anesthesia machines as ventilators.
• March 29: COVID ICU beds open in operating rooms (using anesthesia machines)
• March 31: New York City surpasses 1,000 COVID deaths.
• April 2: COVID ICU expands into two PACU areas (using anesthesia machines), totaling 60 new ICU beds.
• Mid-April: Cornell has 212 patients with COVID-19 on mechanical ventilation.
• April-May: Rapid decline in COVID-19 patients requiring mechanical ventilation. Consolidation of patients back to traditional ICU locations.
• May 10: OR and PACU COVID ICUs close.
• End of May: Gradual resumption of non-emergent surgery.
• June 8: Phase 1 of New York City reopening, 100 days after first COVID-19 case.

Physical Changes During COVID: Retrofitting ORs and PACU Areas
During the initial phases of the COVID surge, COVID-19 patients were placed in various ICUs throughout Dr. Yeung’s institution.  They were then quickly placed into COVID-19 specific ICUs.  However, within three weeks their traditional ICUs were at capacity.  Thus, alternative ICU locations were created in the ORs and PACUs.

The conversion of the OR rooms to COVID ICUs occurred in just three days.  Changes to the physical structure of the ORs included:

1. OR rooms converted to negative pressure rooms.
2. High efficiency particulate air filters installed over exhaust vents.
3. Data ports to connect anesthesia machines to clinical stations in the central core installed.
4. Each OR equipped with two to three beds and anesthesia machines.

A few days later, to convert their PACU areas to additional ICU facilities, the following structural changes occurred:

1. New walls were erected to create negative pressure zones for two to six patients.  Doors had plastic barriers with zipper entrances. 
2. A central nursing station was created surrounded by walled-off zones.
3. Plexiglass windows were inserted into walls to allow viewing of patients.

Staffing Changes During COVID: Pyramid Staffing Model
The emergence of COVID in New York City altered the needs of their patient population.  To meet these needs, new clinical teams were created within Dr. Yeung’s department, including teams like the following:

1. OR Call for emergency surgeries.
2. COVID Intubation team.
3. Critical Care Medicine team.
4. Simulation team: to train clinicians for COVID intubations.
5. Vascular Access team.
6. Prone Positioning team.
7. Tracheostomy team.

At New York-Presbyterian, many non-ICU trained anesthesiologists were also asked to join the Critical Care Medicine team to staff these newly created OR/PACU ICU beds. To support their anesthesiologists in these new clinical rolls, a pyramid-staffing model was used for this team.  

In this model, ICU-trained physicians served as ICU Oversight attendings, overseeing multiple units (caring for 20-50 patients) and serving as a consultant to all ICU patients.  The traditional ICU attending roll (ICU Lead) was filled with non-intensivist anesthesiologists, who took care of 10-20 patients.  They were expected to direct rounds, manage patient care, and could consult the ICU Oversight attending as needed. 

Clinical care algorithms and reference sheets were also created to help ICU Leads in their new clinical rolls.  Fellows were also credentialed as ICU Second attendings and often acted as co-lead with a non-intensivist anesthesiologist attending.  Finally, residents, CRNAs, PAs, and NPs served as ICU First Call, “frontline” workers, taking care of three to five patients each.  This pyramid-staffing model was also applied to the nursing staff as well. 

Figure 1: COVID OR/PACU ICU Physician Pyramid-Staffing model used at New York-Presbyterian Hospital

ICU leadership held daily Zoom meetings at 4pm.  These meetings were recorded for later viewing as well.  During these meetings, the following topics were typically discussed:

1. 24-hour summary of events.
2. Overall state of the ICUs.
3. Clinical pearls/treatment protocol changes/clinical topics for review.

Managing COVID-19 ARDS patients on anesthesia machine ventilators resulted in many practical challenges.  These challenges included:

1. Excessive condensation in the breathing circuit and gas sampling lines.
2. Inability to deliver nebulized mucolytics or active humidification for patients with copious, thick secretions.   Severe mucous plugging of ETTs occurred frequently.
3. Fine tuning of I:E ratios to prevent breath stacking and auto Peeping was difficult on anesthesia machines, especially for patients with high minute ventilation requirements due to hypermetabolic states.  CO2 absorbents required frequent changing. 
4. Coping with anesthesia machines that did not possess advanced functions present on conventional ICU ventilators (like inspiratory hold to estimate plateau pressures).
5. Periodic anesthesia machine system checks required regular disconnection of patients from anesthesia machine ventilators.
6. Anesthesia machine alarms were difficult to hear from the nursing station.

Dr. Yeung related that the overall mortality rate in their OR/PACU ICUs was 41.1%, similar to that seen among critically ill COVID-19 patients overall (39%).  The median age of patients in their OR/PACU ICU was 63 years, 70% were male, and the median LOS was 16 days.   

Finally, to close his talk, Dr. Yeung recounted the two things he felt helped his department make it through this difficult time: (1) Frequent information and communication with hospital administration and departmental leadership, (2) Amazing support - including clinical support from other ICU clinicians, structured psychological support for clinicians, and unstructured departmental Zoom group yoga sessions, game nights, and the like.  Transportation support and daily, prepackaged meals were provided by the hospital and medical school.  

In the end, strong community support was also very helpful during the most difficult times, where a 7:00 pm shout-out to essential workers could be routinely heard ringing throughout the streets of New York City.   

COVID-19 in South Korea

Jong-Rim Lee, MD, PhD (Chief, Pediatric Anesthesia Division, Severance Hospital, Associate Professor of Anesthesiology, Yenisei University College Of Medicine) gave a very interesting talk highlighting South Korea’s COVID-19 experience.

The government of South Korea has been applauded for their ability to effectively control the spread of COVID-19.  South Korea has a population approximately 1/6th the size of the US.  Remarkably, as of Jan 24, 2021, only 74,692 confirmed cases of COVID-19 (1457 cases/million) and 1,337 deaths (1.8% mortality rate) have been recorded.  Overall, South Korea has seen three waves of infection, the last being domestically driven and most deadly.

Figure 1: Overall COVID-19 case statistics (as of 1/24/21) and three waves of COVID-19 infections seen in South Korea.

The Government’s Response
The South Korean government learned a lot from handling an outbreak of MERS in 2015.  As the largest outbreak outside of the Middle East, their experiences in 2015 allowed them to develop the following three measures:

1. Testing Capabilities: Systems were put in place to rapidly upscale sites for community testing.
2. Hospital Designation:  Private and public hospitals were designated as infectious disease centers equipped with negative pressure isolation rooms and other related resources.
3. Korean Center for Disease Control and Prevention (KCDC) was granted greater authority and autonomy.  It is South Korea’s governmental controlling power during an outbreak.  The KCDC was given powers to perform the following functions:  
   • Promote public-private partnership for medical supplies.
   • Authorize emergency use of testing kits and treatments.
   • Enable health authorities to collect personal data for contact tracing.

How did South Korea flatten the curve so successfully? The government was very successful in achieving three main goals: (1) Fast, Massive Testing, (2) Meticulous and Extensive Contact Tracing, and (3) Universal Isolation Measures.

(1) Fast, Massive Testing
Ten days before the first case of COVID-19 was even seen in South Korea, government authorities met on Jan 10, 2020.  They obtained virus genetic information from China and developed a RT-PCR test.  By the end of Jan 2020, a 1-step COVID-19 RT-PCR kit was developed, commercialized, and began mass production.  Additional testing kits quickly followed in the next month.    

Community-based COVID-19 testing facilities were quickly created throughout the country.  Walk-through and drive-through options were widely available and provided results within 24- hours.  The opening of these testing facilities prevented private clinics and hospitals from being overwhelmed with COVID testing needs.  Due to such massive testing, the overall test positivity rate in South Korea has been kept low at 1.5%.  To avoid nosocomial spread of COVID-19 within hospitals, screening clinics closely tied to hospital entrances were also created to screen, triage, and test all visitors prior to hospital entry. 

(2) Meticulous and Extensive Contact Tracing
South Korea is one of the most connected countries, with 95% of citizens accessing the internet on their cell phones daily.  The South Korean government posted on local government websites specific information of all known COVID-19 positive cases to allow citizens to contact trace by themselves.  Detailed information was provided like age, sex, job, movements by the minute, significant places visited (shop/restaurants/public transit), and whether the subject wore a mask.  The same information was also texted to all cell phones that were in close proximity to the known COVID case.  This information was compiled from electronic payment/transaction data, cell phone location logs, and surveillance camera footage.  Fines of $100 were given to those not wearing masks.  Only China’s government has the ability to perform a similar level of surveillance on a population level.

(3) Universal Isolation Measures: Government Quarantine and Treatment Facilities
Initially, all COVID-19 positive patients were to be hospitalized in COVID-19 only hospitals. However, with the rapid rise in cases, there were not enough beds to meet the need. Also, unlike MERS, not all COVID-19 patients required critical care. Isolation of known cases at home was felt to be unsafe due to the Korean housing style.  Thus, the government opened nationally designated, community-based, government isolation facilities in dormitory style buildings for COVID-19 positive individuals that were asymptomatic or had mild symptoms. If their symptoms worsened, patients would then be transferred to a COVID-only hospital.

Thus, all confirmed COVID cases were quarantined in government facilities, including asymptomatic patients.  Twenty to fifty percent of all confirmed COVID-19 cases were sent to these community-based isolation facilities.  In these facilities, they were isolated and remotely visited by doctors and nurses two to three times a day.  They were mostly provided medications for symptomatic relief, including antipyretics, antitussives, and sleep aids.  For those that were asymptomatic at admission, 60% remained asymptomatic during their entire stay.  Two to ten percent of patients were transferred to a COVID hospital due to worsening of symptoms.  Patients were initially discharged from these government isolation facilities when viral remission was achieved and they tested COVID negative.  This occurred after an average of 21 days of isolation.  Currently, patients in these isolation facilities are discharged according WHO guidelines and without achieving viral remission.

Willingness to Wear a Mask
Why are South Koreans so willing to wear a mask?  Some think that this is due to South Korea’s Confucian tradition, which teaches obedience and respect for other people.   However, Dr. Lee does not agree.  She feels that South Korea’s prior experience from previous outbreaks (SARS 2002, H1N1 2009, MERS 2015) and the large amount of air pollution with ultrafine dust made wearing masks the norm in Korea even prior to the COVID-19 pandemic.   As such, high quality disposable masks similar to N95 (called KF94) have been widely available to the general population since 2014.

Challenges Related to South Korea’s COVID-19 Response
Dr. Lee closed her talk by highlighting problems she sees with South Korea’s COVID-19 response.  These include (1) Lack of strict border controls, (2) Issues with privacy invasion, (3) Complicated social distancing policy, and (4) Lack of a COVID-19 vaccine.

(1) Lack of strict border controls
Taiwan and New Zealand both banned entry of all foreigners since the beginning of the pandemic.  In these countries, citizens are currently leading normal lives and their domestic economies are faring better.  In South Korea, 8% of all COVID cases are seen in foreigners.  Despite strong recommendations from experts to institute similar border controls in South Korea, this has not occurred.  Instead, foreigners are asked for a 14-day period of self-quarantine.  Also, no government-mandated testing is required before ending quarantine.  Dr. Lee feels this is concerning because many COVID cases can be missed.  In a study of 20,000 overseas travelers that were quarantined for 14 days, 56 confirmed cases of COVID-19 were seen.  Forty percent (22/56) of COVID cases were found during isolation using voluntary symptom evaluation and testing during the 14-day period.  However, the other 60% (34/56) of COVID cases would have been missed if viral testing was not mandated prior to release (J Korean Med Sci. 2020 Aug 31;35(34):e314).  Nevertheless, the South Korean government still does not mandate testing at the end of quarantine.

(2) Issues with privacy invasion
The South Korean government believes that transparent and accurate information about all COVID-19 positive cases should be widely disclosed to the population. However, this has led to many unintended consequences, including blaming, bullying, and loss of employment of particular individuals if their identity is revealed by the specificity and amount of details released. Shops are sometimes forced to close when publicly connected to a COVID case. Is the disclosure of so much information a fundamental violation of human rights? Dr. Lee believes that South Korea has tried to walk the line of balancing the Public Good vs. Individual Human Rights and has recently improved.

(3) Complicated social distancing policy  
The South Korean government is proud that they have controlled COVID-19 without a total lockdown of activities.  However, Dr. Lee feels that the government’s social distancing policy is very complicated.  Rules differ between different public locations (ex. internet cafés, coffee shops, schools, karaoke rooms, and shops) and each location has different tiers of severity.   However, many of the detailed rules lack a scientific basis.  As a result, publicly known infections has led some sectors to be overregulated while other sectors are underregulated despite being inherently higher risk locations.   The government has also been hesitant to raise levels of social distancing, but has been quick to lower levels.  Dr. Lee believes these factors have contributed to the third wave of domestic COVID cases.

(4) Lack of a COVID-19 Vaccine  
Finally, South Korea is one of the few developed countries that will not have widespread vaccination programs started before Feb 2021.  Dr. Lee feels this factor has been a tremendous oversight from the government, where all of their efforts have instead been focused on controlling the spread of COVID.  In the end, Dr. Lee knows that group immunity is the only way South Korea will finally be really free of the effects of COVID-19.  With the vaccine, she hopes for brighter days for everyone soon. 

Simulation as a Tool for COVID-19 Management

Simulation is an artificial representation of real-world processes that are used to achieve educational goals through experiential learning.  Lisa Caplan, MD, Kathleen Chen, MD, and David A. Young, MD, MEd, MBA are pediatric anesthesiologists at Texas Children’s Hospital and are members of their department’s simulation team. 

Low fidelity simulations mirror clinical scenarios, but leave out many factors that would occur in real life (ex. online symptom checkers). High fidelity simulations strive to be as realistic as possible, simulating real-world relationships and interactions (ex. pilot flight simulators). 

Low fidelity simulations were found to be sufficient for the speakers to achieve their COVID-specific learning goals. 

Example goals that they identified included:

1. Teaching novel perioperative care pathways
   (ex. Patient handoff of a COVID-19 positive patient for an OR procedure with PPE donning)
2. Teaching novel workflow checklists
3. Practicing known skills (ex. Intubating with the challenge of PPE)
4. Learning new skills (ex. Intubating with use of intubation boxes, PPE Donning and doffing techniques)

In their department, in-person simulations were used to teach 780 learners from three campuses from a multidisciplinary pool of personnel, spanning from nurses, scrub techs, physicians, CRNAs, and residents.

Their in-person COVID-19 simulation course was divided in three sections: (1) Didactic on the background of COVID -19, (2) Workshop teaching PPE donning and doffing techniques, and (3) Simulation videos highlighting new intraoperative care pathways for COVID-19 patients.

The barriers that they ran into during the creation of this course included:

1. Time sensitivity for implementation
2. Large, multidisciplinary learner population
3. Limited instructional time due to workforce demands
4. Social distancing restrictions
5. Lack of specific pre-existing policies regarding PPE
6. Limited supply of PPE and need to limit waste

Course evaluation data was used to guide future improvements in their course.  Most participants had positive reviews of the course even six months after completion.  In these evaluations, most agreed or strongly agreed that the course improved their ability to care for COVID-19 patients and provided educational content directly applicable to their practice.