Free
Features  |   May 2020
A Rapidly Evolving Response to COVID-19
Article Information
Infectious Disease / Respiratory System / Features
Features   |   May 2020
A Rapidly Evolving Response to COVID-19
ASA Monitor 5 2020, Vol.84, 14-16.
ASA Monitor 5 2020, Vol.84, 14-16.
Daniel W. Johnson, M.D., FCCM, is Associate Professor, Department of Anesthesiology, and Division Chief of Critical Care, University of Nebraska Medical Center, Omaha.
Daniel W. Johnson, M.D., FCCM, is Associate Professor, Department of Anesthesiology, and Division Chief of Critical Care, University of Nebraska Medical Center, Omaha.
Daniel W. Johnson, M.D., FCCM, is Associate Professor, Department of Anesthesiology, and Division Chief of Critical Care, University of Nebraska Medical Center, Omaha.
×
Muhammad B. Rafique, M.D., FASA, is Associate Professor of Anesthesiology, University of Nebraska Medical Center, Omaha.
Muhammad B. Rafique, M.D., FASA, is Associate Professor of Anesthesiology, University of Nebraska Medical Center, Omaha.
Muhammad B. Rafique, M.D., FASA, is Associate Professor of Anesthesiology, University of Nebraska Medical Center, Omaha.
×
COVID-19 has created unprecedented challenges for the health care community worldwide. As this article is being written, friends and colleagues in the United States and abroad are being asked to provide care for thousands of critically ill patients with infrastructure that is suitable for only a few hundred. By the time this article is in print, the entire landscape of the COVID-19 response certainly will have changed.
For 15 years, the University of Nebraska Medical Center (UNMC) has spent a great deal of time and effort preparing for the threat of dangerous infectious diseases. With one of the largest biocontainment units in the U.S., the only national quarantine unit (NQU), and the Davis Global Center for Health Security, the faculty and staff at UNMC initially felt optimistic that the novel coronavirus emerging in Asia would be a manageable problem. Due to the strong relationship between UNMC and the federal government, many on campus expected to play some role in the response to this infectious threat. At that time, many did not appreciate the enormous worldwide health care challenge that was to come.
On February 7, 2020, a 747 aircraft landed in Omaha to deliver 57 American citizens from Wuhan to Camp Ashland, an Army National Guard training facility, for 14 days of quarantine. UNMC expected to provide care for many of them at the 20-bed NQU or in the 10-bed Nebraska Biocontainment Unit (NBU). After the development of symptoms, one person required a short stint in the NQU, but after testing negative for COVID-19, they were transferred back to Camp Ashland. No other guests at Camp Ashland required care at the UNMC campus. Zero of the 57 guests at Camp Ashland developed COVID-19 during their 14-day stay in Nebraska.
While the Camp Ashland guests awaited the end of their federally mandated quarantine, another cohort of Americans was brought from the Diamond Princess cruise ship, docked in Japan, to the NQU. Several of these people were showing signs of COVID-19 upon arrival, and indeed, many tested positive for the virus. Some of the NQU guests became acutely ill and required transfer to the NBU for closer monitoring, fluids, and oxygen therapy. The specialized team of nurses, therapists, and doctors in the NBU provided care precisely according to the standard operating procedure UNMC had developed for MERS-CoV and for SARS-1 type outbreaks. As patients progressed and recovered, they were transferred back to the NQU. At this point, the team still thought that true containment of the disease within the U.S. was possible.

Now, when the world is at war with COVID-19, anesthesiologists must step up in a way like never before. By utilizing the unique combination of knowledge, procedural skill and administrative expertise, physician anesthesiologists can help the world return to normal as swiftly as possible.

Personal protective equipment (PPE) is a very hot topic of discussion and debate. The NQU has hosted 23 guests in February and March 2020, many of whom were symptomatic and tested positive for COVID-19. Throughout this two-month period, UNMC nurses, doctors, and therapists all used the same PPE: N95 respirator mask, gown, gloves, and face shield. At the time that this article is being written, zero health care workers in the NQU or the NBU have contracted COVID-19 as a result of providing care to COVID-19-positive patients. In 2014, dozens of UNMC health care workers provided care for three patients with Ebola virus disease. Zero hospital employees contracted Ebola. These statements are not meant as self-congratulation. Rather, they are meant to reassure colleagues all over the world that the proper use of PPE does protect health care workers from this disease.
An anesthesiologist-intensivist placing an ultrasound-guided central line during an activation of the Nebraska Biocontainment Unit. © Elsevier Inc. All rights reserved. Used with permission, from Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier, Inc; 2020:Figure 68.21.
An anesthesiologist-intensivist placing an ultrasound-guided central line during an activation of the Nebraska Biocontainment Unit. © Elsevier Inc. All rights reserved. Used with permission, from Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier, Inc; 2020:Figure 68.21.
An anesthesiologist-intensivist placing an ultrasound-guided central line during an activation of the Nebraska Biocontainment Unit. © Elsevier Inc. All rights reserved. Used with permission, from Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier, Inc; 2020:Figure 68.21.
×
Aside from the people who had been evacuated from the Diamond Princess, the first several cases of COVID-19 in Omaha were all related to people returning from travel to Asia, Europe, or heavily affected areas within the U.S. Several weeks after the first travel-related case of COVID-19 in Omaha, public health officials detected two cases that were not clearly travel-related. This meant that community spread was occurring. When public health leaders realized that community spread was occurring within the Omaha area, the NQU and NBU team knew that a change in strategy was necessary. Containment had been successful in the sense that no guest or patient of the NQU or NBU had transmitted the disease to a health care worker or to anyone else in Omaha. Instead, COVID-19 arrived to Omaha by way of travelers, and mitigation of community spread was the new challenge.
UNMC anesthesiologist-intensivists (who routinely staff the NBU) played a major role in the response to community spread of COVID-19 both at the hospital level, the city level, and nationally. Hospital leaders had been meeting and planning for a response to the COVID-19 threat for weeks, and they relied on frequent input from the UNMC Department of Anesthesiology for expert opinions on PPE, resource allocation, and staffing plans for a potential surge in patients. Leaders in anesthesiology pushed, in conjunction with leaders in the department of surgery, to heed the advice of Italian colleagues, ASA, the Surgeon General Jerome Adams, and the American College of Surgeons to halt all elective surgeries to help create hospital capacity and reduce the utilization of precious PPE. One of the main factors driving the timing of canceling elective surgeries was the need to have buy-in from all of the major hospital systems in the Omaha area. If only part of the city stopped doing elective surgery, the hospitals that failed to cancel cases would simply absorb the excess case volume, and overall hospital capacity would be unaffected. The leaders of all major health care systems in Omaha met multiple times, and with support from the state of Nebraska, agreed upon March 20, 2020 as the day when elective cases would be postponed or canceled. In an effort to help “flatten the curve” and avoid the health care system becoming overwhelmed, anesthesiologists used social media platforms to appeal to the lay public. A letter written by a UNMC anesthesiologist to his family was posted on social media and subsequently went viral, generating more than 3 million views in a two-day period (www.nebraskamed.com/COVID/a-message-from-one-of-our-doctors-to-his-family-about-covid-19).
The entire UNMC community recognized that COVID-19 was no longer a problem limited to the NQU, the NBU, or any other single unit. Physician and nursing leaders realized that a successful response to COVID-19 would require a robust effort from the entire hospital and the entire Omaha community. Patients were transferred from the 10-bed NBU to a 24-bed negative pressure ICU. Nursing leaders from the NBU immediately transitioned into hospital-wide PPE consultants, available to all hospital staff to ensure that all health care workers were safe in their approach to the care of COVID-19 patients. PPE plans were modified to reflect the need for safety combined with sustainability. NBU nursing leaders swiftly created educational modules for the safe donning and doffing of PPE. Anesthesiologists were instrumental in promoting the conservation, recycling, and reuse of PPE.
Very early in the hospital-wide response, the department of anesthesiology reached out to the departments of internal medicine and surgery to ensure that all of resources of adult critical care would be working as a cohesive team to confront the pandemic. Critical care division chiefs met by video conference on a daily basis to ensure a coordinated effort. Silos of critical care appropriately disappeared. Everyone shared the same goal: save as many lives as possible and achieve this with the smallest risk of harm to health care workers. A single patient care tower was identified as the location where COVID-19 patients would be cohorted. This required the relocation of more than 100 non-COVID patients. This relocation would not have been possible without the prior cancellation of elective surgeries, which created enough vacant beds in other patient care towers.
UNMC leaders were in frequent communication with the leaders of other regional health care systems to ensure that all parties understood that the COVID-19 pandemic was not a problem belonging solely to the area’s flagship academic medical center. Rather, it was a behemoth requiring a massive response by all of the hospitals in the region.
UNMC anesthesiologist-intensivists created a “Critical Care Tiered Surge Staffing Response.” In early phases of the response, intensivists from internal medicine and anesthesiology work collaboratively, within their normal critical care infrastructure, to care for COVID-19 patients. Later phases of the response require an entirely new approach to critical care, in response to a massive surge of critically ill patients. In the Tiered Surge Response, one intensivist serves as a supervising consultant to five (non-intensivist anesthesiologists, each of whom is responsible for up to eight patients with COVID-19. Each “micro-team” of eight patients has at least two resident physicians, nurse practitioners, physician assistants, or CRNAs. This approach leverages the extraordinary skill set of physician anesthesiologists, who take care of critically ill patients with respiratory failure in the O.R. on a daily basis. Anesthesiologists are experts at managing mechanical ventilation on extremely ill patients, and the COVID-19 pandemic required UNMC and many other hospitals to call upon these doctors to work outside their normal environment in order to save lives.
The COVID-19 pandemic is the worst infectious disaster this generation of physicians has ever faced. Hospitals, cities, states, and indeed the world are all looking to anesthesiologists to utilize their expertise to help mitigate the damage that this awful viral illness might do. Anesthesiologists demonstrate leadership and courage on a daily basis during “peace time.” Now, when the world is at war with COVID-19, anesthesiologists must step up in a way like never before. By utilizing the unique combination of knowledge, procedural skill and administrative expertise, physician anesthesiologists can help the world return to normal as swiftly as possible.
Daniel W. Johnson, M.D., FCCM, is Associate Professor, Department of Anesthesiology, and Division Chief of Critical Care, University of Nebraska Medical Center, Omaha.
Daniel W. Johnson, M.D., FCCM, is Associate Professor, Department of Anesthesiology, and Division Chief of Critical Care, University of Nebraska Medical Center, Omaha.
Daniel W. Johnson, M.D., FCCM, is Associate Professor, Department of Anesthesiology, and Division Chief of Critical Care, University of Nebraska Medical Center, Omaha.
×
Muhammad B. Rafique, M.D., FASA, is Associate Professor of Anesthesiology, University of Nebraska Medical Center, Omaha.
Muhammad B. Rafique, M.D., FASA, is Associate Professor of Anesthesiology, University of Nebraska Medical Center, Omaha.
Muhammad B. Rafique, M.D., FASA, is Associate Professor of Anesthesiology, University of Nebraska Medical Center, Omaha.
×
An anesthesiologist-intensivist placing an ultrasound-guided central line during an activation of the Nebraska Biocontainment Unit. © Elsevier Inc. All rights reserved. Used with permission, from Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier, Inc; 2020:Figure 68.21.
An anesthesiologist-intensivist placing an ultrasound-guided central line during an activation of the Nebraska Biocontainment Unit. © Elsevier Inc. All rights reserved. Used with permission, from Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier, Inc; 2020:Figure 68.21.
An anesthesiologist-intensivist placing an ultrasound-guided central line during an activation of the Nebraska Biocontainment Unit. © Elsevier Inc. All rights reserved. Used with permission, from Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier, Inc; 2020:Figure 68.21.
×
0 Comments
Submit a Comment
Submit A Comment

Contributors must reveal any conflict of interest. Comments are moderated.

Name
Affiliation & Institution
I have a potential conflict of interest
Comment Title
Comment


This feature is available to Subscribers Only
ASA Member Login or Create an Account ×