key: cord-255867-moriv0va
authors: Sheth, Parth D.; Simons, Jessica P.; Robichaud, Devon I.; Ciaranello, Andrea L.; Schanzer, Andres
title: Development of a Surgical Workforce Access Team (SWAT) in the Battle Against COVID-19
date: 2020-04-30
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.04.493
sha: 
doc_id: 255867
cord_uid: moriv0va

nan

The spread of the novel SARS-CoV-2 coronavirus and its resulting COVID-19 disease 2 has transformed the landscape of healthcare worldwide. First identified in China in December 3 2019, it has rapidly spread across the world, with major outbreaks occurring initially in China, 4 Iran, Italy, and Spain. The first case in the United States was identified on January 20, 2020, and 5 it has proliferated across the country since then. 1 COVID-19 disease is characterized by rapid 6 respiratory compromise, and affected patients frequently require long intensive care unit (ICU) 7 stays. Because of its severity and rapid transmissibility, the World Health Organization declared 8 the disease a pandemic on March 11, 2020 . At the time of this writing, there have been over 1.2 9 million confirmed cases worldwide, with 320,000 cases and 9,000 deaths in the United States. 2 10 11 Several features of COVID-19 have allowed it to proliferate rapidly. It appears to spread 12 much more readily than other respiratory viruses such as seasonal influenza, 3 and it has a long 13 incubation period during which asymptomatic individuals can transmit to others. 4 Once patients 14 become symptomatic, there is a high rate of severe respiratory compromise that may require 15 treatment in an ICU; preliminary data from Italy suggests that 16% of COVID-19 patients 16 required ICU management. 5 The long length of stay and high resource utilization required for 17 these patients pose particular challenges within the context of the American healthcare system. This reduction in surgical volume has allowed us to make changes to the traditional, 19 established models of provider staffing. Our institution has addressed the increased demand for 20 critical care providers by redeploying anesthesiologists to ICUs. It has also redeployed most 21 medical subspecialty fellows to general medicine teams, where they may practice independently by virtue of their primary board certification. Providers in surgical fields, especially residents, 1 have likewise been redeployed to ICUs and medicine teams. Advanced practice providers have 2 been shifted to the emergency department, testing centers, and call center teams triaging 3 COVID-19 patients. 4 5 In addition to supporting these institutional changes, our division assessed vascular-6 specific additional opportunities to contribute. We set out to answer the following three We ultimately decided that creating a vascular access team would allow us to best 17 address each of these questions, while utilizing our unique skillset to assist the hospital's efforts with ICU providers in heavily affected areas such as Italy, New York, and Washington, we 5 became aware that these line placement procedures consumed a large portion of time for critical 6 care providers. As vascular surgeons, we are uniquely positioned to quickly and efficiently 7 perform these bedside procedures, thereby offloading other providers to focus on areas where 8 their skillsets are best utilized. We worked with our institutional leadership to establish a 9 vascular access team with clear, strong guidelines to signal our commitment to the critical care 10 teams; in particular, we established the following key parameters (Table I) : 11 12 • The team will be responsible 24/7 for placing all central venous lines, arterial lines, and 13 temporary dialysis catheters for inpatients on the main campus of our hospital system. 14 • The team will commit to provide a page-to-puncture time of 60 minutes or less.

We also worked with our critical care colleagues to develop a multidisciplinary, 17 standardized, algorithm to guide optimal locations for line placement. Prone ventilation has been 18 recommended for adults with severe acute respiratory distress syndrome due to COVID-19 for 19 12-16 hours per day to improve lung recruitment. 7 Based on conversations with colleagues in 20 Italy 8 , temporary dialysis lines function most consistently when placed in the right internal 21 jugular vein position for patients who are proned. Our multidisciplinary team also concluded that avoiding catheter-related infections was a top priority, as these can be devastating in patients 1 who are already critically ill. Therefore, we place dialysis catheters in the following preferred 2 order: right internal jugular vein, left internal jugular vein, subclavian vein, femoral vein. To 3 preserve the right internal jugular vein for dialysis catheters, we place central venous catheters in 4 the following preferred order: left internal jugular vein, right internal jugular vein, subclavian 5 vein, femoral vein. For arterial access, we prioritize radial artery, followed by brachial artery, 6 followed by femoral artery. Our goal was to create a staffing model that was scalable based on volume in order to 11 respond to a projected surge of patients. In addition, we want to be able to replicate this model at We structured our coverage so that each SWAT team works a 12-hour shift, 7 days in a 21 row. Because of the 60-minute page-to-puncture commitment, these SWAT teams stay in house while on duty. Staying in house also allows the SWAT team to provide 24/7 coverage for all 1 vascular surgery floor and consult patients, thereby relieving the general surgery night float 2 residents from having to cover these patients and freeing them up to take on other COVID-19 3 related responsibilities. To maintain compliance with the ACGME 80-hour workweek averaged 4 over a 4-week period, providers work for 2 weeks followed by a week off. In case of a vascular 5 surgical emergency, or if multiple line requests arrive in rapid succession, there is a backup team 6 available that is called in to maintain continuous coverage. Table II ) and a 10 duplex ultrasound machine. Because we anticipate that this service will be required for several 11 weeks, we worked with our hospital's supply chain team to ensure a sustainable daily resupply 12 mechanism with fixed par levels for each item. We believe this method will provide significant 13 benefits over ad-hoc stocking from existing supply pools, especially as volume increases.

14 Additionally, a two-person team maintains efficiency while minimizing the number of providers 15 involved per line placement, thereby reducing the use of PPE (Table III) .

A further benefit of basing our staffing model around two-person teams is that it 18 maximizes healthcare worker availability. Data from China, Italy, and Spain suggests that there 19 is a high incidence of COVID-19 infection among healthcare workers. At our institution, we did 20 have one team member develop symptoms, but the individual fortunately ruled out and 21 subsequently improved. We designed our structure with a backup pool to maintain continuity of coverage while allowing affected providers to rest and recover, and we were able to do so in that 1 case. In response to the COVID-19 pandemic, our vascular surgery division has implemented a 6 24/7 vascular access team to provide line placement services throughout our medical center. We 7 believe this model allows us to maximize our skillset while providing an important service for 8 the hospital during this crisis. Additionally, this model allows us to control our own workforce 9 and preserve workforce availability in the likely event that some of our providers contract the 10 disease.

While the specific needs at each institution across the United States and the world will 13 vary, the need for timely and expert line placement in these critically ill patients will exist 14 everywhere. We believe that vascular surgeons are uniquely positioned to deliver this service 15 expeditiously and safely. We hope that by taking these time-intensive procedures out of the 16 hands of our critical care and medicine colleagues, they will be better positioned to leverage their 17 expertise in caring for COVID-19 patients. 

COVID-19) Pandemic. www.who.int/emergencies/diseases/novel-coronavirus-2019

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