In a recent interview with ASA Monitor, John S. Mercer, MD, Department of Anesthesia, Columbia University College of Physicians and Surgeons, discussed his department's experience dealing with the COVID-19 pandemic during the early part of 2020. “One of the first things that we had to do was mentally prepare ourselves for the tremendous challenges in front of us,” Dr. Mercer explained. Department physicians encountered significant changes to their daily routines, but once they embraced these changes, the new normal became easier to manage.
Workload
The pandemic greatly affected anesthesiologists' workloads. “Prior to the outset of the pandemic, approximately 90%-95% of our case load involved perioperative assistance and 5%-10% consisted of critical care cases,” Dr. Mercer stated. “At the height of the pandemic, the ratio had nearly flipped, with approximately 80% of our cases being critical care.” On an ordinary pre-pandemic day, the department could expect approximately five intubations, but at the height of the pandemic they performed approximately 25 to 30 of these procedures each day.
The myriad tasks that constituted their new COVID-related assignments included critical care assistance, respiratory therapy, ventilation, oral care, and bedside physician work – a task that was previously reserved for interns.
Lessons learned
“One of the first things we implemented, even before we had seen our first COVID patient,” Dr. Mercer noted, “was the use of COVID ‘to-go’ kits.” The idea for this new tool was provided by an anesthesiologist who had spent time with Médecins Sans Frontières (MSF, or Doctors Without Borders) treating the Ebola breakout in West Africa in 2014. These kits included all the appropriate PPE (for example, masks, gowns, gloves, and face shields) for two providers.
After managing documented cases of COVID-19, one of the first things the department learned was to let go of any pre-conceived notions regarding this disease. “Initially, we thought that we would mainly be dealing with ventilation and ARDS (acute respiratory distress), and although there was a significant amount of those, there were also many surprises,” Dr. Mercer recounted. One such surprise was the occurrence of various coagulopathies. Dr. Mercer and his colleagues quickly learned to adapt to the ever-changing landscape of this disease, often making adjustments on the fly.
“We quickly discovered that communication was paramount; we needed an organized method of communication so that we were not answering the same clinical questions multiple times,” Dr. Mercer stated. For example, many physicians had primarily care-related questions regarding the use of proper PPE or safety issues. Answering the same questions multiple times drastically reduced their efficiency. Answering emails grew into an extremely onerous task, as they frequently received over 100 emails after only a few hours on the floor. As a result, the department established a centralized communication director who was able to streamline this process, avoiding duplicated efforts.
Another important communication adjustment was the use of a family service liaison who helped the anesthesiologists connect with family members. “COVID-19 created some unique problems for patients and their families, especially regarding visitation and determining their patient's status,” Dr. Mercer said. “The creation of this post was very important in developing relationships with our patients' families, and this was actually very moving for all parties involved.”
Conclusions
Noting the success of their protocols, Dr. Mercer observed, “Not one member of the airway team physicians was infected as a result of their work at our hospital; our procedures were completely effective at preventing transmission to our staff.” He attributed this win to proper adherence to guidelines with appropriate PPE and scrupulous handwashing.
The cooperation of the community was another critical contributor to the department's success. When the people in the community do everything that they can to reduce the caseloads for their first-line responders, they are helping clinicians make the best use of their equipment and resources by not overwhelming the health system. Dr. Mercer also noted that community cooperation was also important to the morale of their staff; the seriousness with which community members approached the disease conveyed to health care workers how much their work is truly valued.
Another big takeaway was the importance of administrators taking care of front-line staff by ensuring that they are properly rested and well-fed, and that the appropriate mental health professionals are available to assist front-line employees. “In addition, administrators must, if necessary, make their front-line employees take their vacation time so that they do not become overworked,” Dr. Mercer said. “We found that when vacation time is not taken, this can rapidly lead to burnout.”
According to Dr. Mercer, the integration of all these methods allowed them to successfully navigate through this pandemic. By June 8, they were able to resume elective surgeries, returning to approximately 90% of their pre-COVID levels as of August 5.
