key: cord-272585-346ef6qy
authors: Lombardi, JM; Bottiglieri, T; Desai, N; Riew, KD; Boddapati, V; Weller, M; Bourgois, C; McChrystal, S; Lehman, RA
title: Addressing a National Crisis: The Spine Hospital and Department's Response to the COVID-19 Pandemic in New York City
date: 2020-05-31
journal: Spine J
DOI: 10.1016/j.spinee.2020.05.539
sha: 
doc_id: 272585
cord_uid: 346ef6qy

In a very brief period, the COVID-19 pandemic has swept across the planet leaving governments, societies and healthcare systems unprepared and under-resourced. New York City now represents the global viral epicenter with roughly one third of all mortalities in the United States. To date, our hospital has treated thousands of COVID-19 positive patients and sits at the forefront of the United States response to this pandemic. The goal of this paper is to share the lessons learned by our spine division during a crisis when hospital resources and personnel are stretched thin. Such experiences include management of elective and emergent cases, outpatient clinics, physician redeployment and general health and wellness. As peak infections spread across the United States, we hope this article will serve as a resource for other spine departments on how to manage patient care and healthcare worker deployment during the COVID-19 crisis.

Although from an early age I'd learned from Charles Darwin and others that species adapt naturally to their environment, in the moment, that adaptation is often a painful process. The onset of COVID-19 and the changes forced upon us by science, common sense, and our survival instinct have been a strong reminder of the challenges true adaptation involves. This spring's events have felt familiar to me -I'd already lived a similar experience. In the first weeks after taking command of Joint Special Operations Command (JSOC), it became apparent we were losing the battle to Al Qaeda in Iraq (AQI). JSOC, America's elite counter-terrorist task force, was built to operate in small teams conducting elegant, but infrequent, precise strikes. We were the most efficient and effective counter terrorism force in existence -but we were not adaptable. We'd never really had to be.

Al Qaeda in Iraq (AQI), however, changed the rules by morphing faster than our slow, but precise, operations could counter. A target, or fleeting opportunity, that was located in the morning was typically gone by evening. Against an enemy that operated differently than anything we had seen before, we had to change. Unsure of what the right answer was, we started from the reality that the one course of action for which we had reliable data, the status quo, was failing. So, we adopted a policy of "question how we do everything". Nothing was held sacredwe needed to find out what worked to defeat AQI and we needed to do it quickly. It was disconcertingly disruptive for a force inclined to developing and then refining to near perfection our tactics, but it worked. We iterated adaptations until JSOC became instinctively flexible and wickedly fast.

The reality for most organizations is that they do not adapt until they are forced to do so.

What is often touted as a leader's foresight or vision was really driven by the reality of a burning platformchange or grow irrelevant; adapt or die.

For America's Healthcare Teams, the fight against COVID-19 is not just the search for a vaccine or management of ventilators. It is adapting every aspect of managing the care of patients. Leveraging virtual interaction, mining growing bodies of data, and realizing that not all care will wait until we return to status quo anteit has to continue on now, but safely. And it must be delivered by healthcare professionals who are performing the extraordinarily complex tasks they always have, but now in the vastly more difficult COVID-19 environment.

All this is doable, because it has to be. It's also possible because the patient-centric mindset that drives the people who've chosen to care for others will drive it. It isn't easy and won't get much easier -but it's working and will only get better.

On December 31 st , 2019, local health officials in the Chinese province of Hubei reported 41 cases of a mysterious pneumonia to the World Health Organization (WHO) 1 . While viral pneumonias are commonplace, this cluster was particularly unusual in that a high percentage of patients was responding poorly to typical supportive measures and becoming critically ill. It was soon recognized that this illness was being caused by a never-before-seen coronavirus subsequently named the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with its infectious manifestation termed the coronavirus disease 2019 (COVID-19) 2-3 . The outbreak was reportedly centered on a wet market in the city of Wuhan, China, but quickly spread 4 The speed and intensity with which the virus spread has left governments and healthcare systems unprepared, under-resourced and without enough personnel to adequately respond. Particularly hard hit has been New York City, which is now one of the global viral epicenters. As of April 28 th , there were a staggering 17,682 mortalities in New York City alone, representing over 30% of all COVID-19-related deaths in the United States 6 . According to the University of Washington's Institute for Health Metrics and Evaluation (IHME), the peak hospitalization rate in New York will occur during the second week of April, preceding the majority of the United States 7 . Our institution has been on the forefront of the COVID-19 pandemic, as we treated "patient zero" in New York City, who presented to our Emergency Department (ED) on February 28 th . To date, we have treated over 5,000 COVID-19 positive inpatients in the epicenter of the viral pandemic with strained resources. Our experiences may serve as a model for other institutions to prepare as their regions approach peak infection. Therefore, the purpose of this paper was to describe our orthopaedic departments' approach towards 1) management of elective cases and outpatient visits, 2) management of "emergent" surgical cases, 3) redeployment of orthopaedic personnel, and lastly 4) maintaining protection and well-being within the department.

Published data by healthcare providers in Asia and Europe demonstrated that the most substantial threat to COVID-19 patient morbidity and mortality was the lack of adequate critical care resources including intensive care unit (ICU) beds and respiratory support [8] [9] . Early reports from Lombardy, Italy, exposed the strain of widespread community transmission on hospital ICU capacity 10 consultation or a telemedicine consultation. Telemedicine visits were found to be noninferior with 98% of virtual visits rated as "good" or "very good" by surgeons 23 

There can be ambiguity when attempting to determine which surgical procedures are elective, urgent or emergent. Additionally, conflict may arise among healthcare providers when attempting to prioritize cases in the setting of severely limited personnel, resources and ventilators. Therefore, our institution sought to create a two-step process to determine both the urgency of cases and the order in which they should proceed. First, a directive was given to create clear guidelines for determining surgical urgency from both an institutional as well as a departmental/divisional standpoint. Those cases that met institutional and departmental criteria were then directed to an independent hospital panel that would determine their priority.

At the time all elective cases were cancelled, our institution published criteria for case escalation, which would serve as a basis for categorizing the urgency of cases across all sites. (Figure 2 ) Emergent cases were classified as those that are life or limb-threatening and would require access to the operating room within 30 minutes. These cases would allow for "bumping" of any service into any available operating room when applicable. Urgent cases were defined as those requiring an operating room within eight hours and would allow for "bumping" within their surgical service (i.e. orthopaedics bumps orthopaedics). Add-on cases were defined as those that should be performed within 24-48 hours, lending priority to long bone fractures. Lastly, the "to consider" classification was given to those patients whose cases were not time sensitive, but whose discharge from the hospital was pending surgical intervention. The institution published a sample list of cases across all specialties and where they fall into the criteria for escalation.

To date, there are no published articles detailing how to best allocate resources and prioritize urgent/emergent cases within a spine division during times of crisis. On April anonymous to the public and employees of our institution. We have received many calls from colleagues across the country whose hospitals have established an intradepartmental committee to determine which cases are urgent or semi-emergent. Yet without anonymity, it is impossible to remove personal interests from the decisionmaking, which may be at odds with key members of the team. When making decisions on the urgency and priority of cases, this committee takes into account guidelines from the CDC, WHO, New York State Department of Health and New York City Department of Health, as well as appropriate subspecialty academy guidelines. In an environment with limited hospital resources and personnel, this committee serves to remove the ethical and legal burden from surgeons while also serving the best interests of not only the patient but also the community as a whole. It is important to note that there are limitations to this system, which include review of cases by surgeons and/or lay people that is outside of their direct area of expertise. 30 . It is not currently the standard of care for surgeons to be wearing N95 masks while operating, thus potentially exposing them to substantial risk in the period following intubation. With this understanding, the use of N95 masks and full-face shields has quickly become implemented into our operative PPE protocol. In an effort to protect both our patients as well as our staff, our institution has mandated that all patients be tested for COVID-19 with a nasal swab viral PCR when admitted to the hospital and prior to proceeding to the operating room.

Recognizing these potentially devastating risks to the operative team, our department developed a protocol in conjunction with the Department of Anesthesia that is designed to minimize exposure to aerosolized viral particles. We identified three distinct phases during the surgical episode where attention should be paid in order to limit transmission: 1) OR preparation, 2) Intubation and 3) Extubation.

During this phase, one should remove all non-essential equipment from the operating room such as IV poles, IV pumps, rapid infusor systems, suture cart etc. Medication and equipment expected to be needed during the case should be removed from the anesthesia cart and the drug-dispensing unit and placed on a clean, easily wipeable surface. One should close all drawers, cover the anesthesia cart and drug-dispensing unit with a plastic drape, and try to avoid accessing it during the case. One should have emergency medication and equipment nearby in a closed bag, so it is easily accessible if needed but does not get contaminated during the procedure. The anesthesia machine has to be protected with a HEPA filter.

With very few exceptions, most spine surgeries require endotracheal intubation. Operating rooms are a positive pressure environment. Therefore it is recommended that if a negative pressure room is available, the patient should be intubated there and then transported back to the operating room. If such a room is not available, the intubation will take place in the operating room. After preparation of the OR as detailed above, all non-essential personnel, including the surgical team, should leave the room. All anesthesia providers must wear PPE including N-95 masks, impermeable gowns, face shields or goggles, double gloves, shoes and head covers. Additionally, a transparent drape should be placed over the patient's head, neck and shoulder area to contain the area of potential respiratory expectorants during induction. This drape can be removed after completion of the intubation process.

The patient should be pre-oxygenated for several minutes. A rapid-sequence induction to achieve optimal intubating conditions in the shortest possible time is the preferred method of induction. This avoids mask ventilation with highly aerosolizing potential.

A video-laryngoscope is preferred for intubations as it allows the anesthesia provider to keep greater distance from the patient's oral cavity. The endotracheal tube cuff should be inflated immediately, the endotracheal tube (ETT) should be connected to the anesthesia circuit and ETCO2 confirmed. It is vital at this time to adequately secure the endotracheal tube. Although an endotracheal intubation is an aerosolizing procedure, an unsecured airway over the whole length of the surgery may have greater potential to create aerosolized viral particles than the intubation itself. For auscultation of breath sounds a disposable stethoscope should be used. Patients presenting for spine surgery, in particular surgery involving the cervical spine, frequently require other methods of securing the airway. In order to protect the patient from further injuries to a potentially unstable cervical spine or in patients with an anatomically difficult airway, a fiber-optic or an awake fiber-optic intubation is often the only safe method of endotracheal intubation. These procedures carry a very high risk of contaminating the environment by respiratory expectorants and should be avoided if possible. If necessary, they should be performed in a negative pressure environment. Putting the patient in a prone position usually requires disconnection of the ETT from the circuit in order to minimize risk of ETT displacement. In these patients the anesthesia practitioner should carefully weigh the risk of ETT displacement versus aerosolizing infectious material when disconnecting the ETT.

The surgical team is advised to re-enter the operating room only after the air has circulated through one cycle, which will vary depending on the specific number of air changes per hour set by that institution. The surgical team and support staff are advised to wear N95 masks throughout the procedure with appropriate eye protection. If the situation requires an awake fiber-optic intubation in the positive pressure environment of the operating room, the surgical team should consider entering the operating room after the air has circulated through several cycles in order to reduce the viral load in the air.

Standard PPE with an N95 respirator and eye protection is of course paramount for all practitioners entering the operating room.

If a negative pressure room is available, the patient should be transferred after completion of surgery for removal of the endotracheal tube. It is recommended to cover the patient's face and upper torso with a clear plastic drape and extubate under that cover in order to avoid dispersing infectious material. Standard PPE has to be worn and all non-essential personnel should leave the room, whether extubating in a negative pressure environment or in the operating room. Patients should be extubated to nasal cannula, face tent or nonrebreather facemask. High flow nasal cannula and Bi-pap should be avoided due to the high potential for viral aerosolization from these oxygen-supplying modalities. If possible, nebulized medications should likewise be avoided because of the highly aerosolizing nature of this application method.

It became clear from an early point that the prospect of orthopaedic surgeon redeployment to other areas of need within the hospital was a distinct possibility. This was due in part to anecdotal reports of redeployment in viral epicenters as well as through correspondence with colleagues in Europe and Asia. Moreover, on March 23 rd , the governor of New York mandated that all hospitals within the state increase their ICU capacity by 50% 31 . This increase in capacity had to be met with an increase in skilled workforce including nursing staff as well as physicians. By March 28 th , exactly one month following the presentation of patient zero to our institution, the first orthopaedic team was redeployed to the ED.

In order to spread the burden evenly across our department, a committee was convened by remote meeting and charged with planning redeployment strategically. It was decided to deploy teams of two providers to the ED, composed of one attending and one resident. Each volunteer was asked to submit his or her age and medical comorbidities, which were kept anonymous to the rest of the department. Risk factors for severe COVID-19 infections were identified and included age >60, HTN, DM, CV disease, obesity and immunosuppression 32 . Other considerations taken into account included child-care needs and ability to quarantine from members of the household. Lastly, those who had a known or suspected prior COVID-19 exposure and had recovered were placed at the top of the list under the assumption that they had obtained short-term immunity, although at this time it is unclear if or when immunity to SARS-Cov-2 is conferred.

( Figure 6 ) An antibody test, when available, will also help in the risk stratification as a significant number of healthcare workers have likely been exposed but are asymptomatic or have a mild illness with immunity. Housing outside of primary residences was made available for volunteer faculty and house staff to help eliminate concerns about spreading the virus to one's family. Faculty and house staff were then ranked for deployment depending on their risk stratification. It is vital to note that although redeployment was an important initiative to our department during this time of crisis, our primary concern was to maintain an adequate workforce to meet all orthopaedic surgical demands at our institution.

When structuring the redeployment schedule, the risk to providers must be considered. It became clear that the number of exposures and duration of exposure should be limited to avoid overburdening clinicians in COVID positive areas. While 12-24 hour shifts may be preferred among some surgeons, we advocated for shorter, 6-8 hour shifts to spread the risk out over a larger number of clinicians. The logistics of this type of deployment limit the number of times in each shift that PPE needs to be donned and doffed and also reduces fatigue. Ultimately deployment shifts were split between multiple departments which further limited repeated exposure to our team. (Figure 7) . These teams would rotate to ensure that needs in the ED were met at all hours of the day, every day of the week. Initially, orthopaedic surgeons and urologic surgeons shared ED coverage.

Eventually, otolaryngology and ophthalmology joined the redeployment efforts. The staffing for these deployments should be based upon the skill set of the respective surgical services. Several of the spine surgeons (and especially the neurosurgeons) have intensive care unit (ICU) experience, and may be better off deployed to assist with the ventilated patients.

Due to aggressive measures taken by the hospital to divert low acuity patients, the total number of daily ED visits was not dramatically increased. However, the acuity of patients who necessitated prolonged ICU stays rose significantly. This led to increased critical care needs within the ED and the ICU. While the precise duties of redeployment vary depending on the assigned location, the overall role of the orthopaedic surgeon was to provide support to the critical care team. Typical duties included obtaining arterial blood gasses for ventilated patients, placing orogastric and nasogastric tubes, assessing for adequate sedation, adjusting ventilator settings, monitoring vitals, ordering blood pressure support and sedative medications, communicating between medical and consulting teams, and even aiding in patient transport between the units.

Particularly challenging was the preservation of PPE due to its critically short supply. Due to the virus' capacity to be aerosolized, N95 masks are recommended wherever aerosolizing procedures are commonly performed, primarily the ED and the ICU 30 . These procedures include intubation, extubation, bronchoscopy, cardiopulmonary resuscitation (CPR), non-invasive positive pressure ventilation (NIPPV), high flow nasal cannula, and nebulization. Ideally these procedures would be performed in a negative pressure room, but with the high volume of patients necessitating these procedures in the ED it was not deemed possible. Given the significant shortage of PPE, each provider was given one N95 mask at the beginning of his/her shift and expected to wear that mask throughout the shift or until it was visibly soiled. In order to prevent the N95 from becoming contaminated by droplets, it was covered with a typical surgical mask followed by a face shield. When the N95 mask had to be removed, such as for eating or drinking outside of the unit, the surgical mask would be replaced, allowing the respirator to be 

In times of crisis, the similarities between physicians and soldiers become more evident.

Both professions play an irreplaceable role in our society, seeking to serve for the greater good of the public. The following lessons have been adapted from soldiers' accounts in the battlefield and applied to our experiences during the COVID-19 pandemic 33 .

1. Embrace the Buddy System: The environment that healthcare providers face during the COVID-19 pandemic will in many ways be unfamiliar. This includes exposure to a novel pathogen that can endanger the health of physicians working on the front line. Having a "battle buddy" will serve as a physical and psychological crutch to keep providers out of harm's way. During our department's redeployment, battle buddies were charged with making sure their partner always had proper PPE, maintained safe procedural practices, and assisted in collective medical decision-making.

2. Prepare for the Unexpected: Rarely in our nation's history have healthcare systems been stretched so thin in such a short amount of time. It is vital for departments to remain flexible and prepared for worst-case scenarios. This includes lack of adequate PPE, team members unable to contribute due to illness, surges of new patients and absence of typical support staff. Taking the time to reflect on "what can go wrong" will enable institutions and departments to be better prepared.

3. This is a Team Effort: In every organization there are members who contribute to varying degrees. It is vital for the leaders in each department to recognize what each of their members' strengths and weaknesses are and to utilize them appropriately. By involving the entire department in decision making and redeployment, leaders can achieve camaraderie and a common sense of purpose.

In our department, we recognized who was at higher risk for complications from the COVID-19 pandemic and deprioritized them for redeployment. Those providers instead increased their telemedicine visits as their primary contribution.

Our department recognized the dangers that fatigue can have on physicians who were deployed to COVID positive areas. Any lapse in stringent airborne and droplet precautions can have catastrophic repercussions. For this reason we implemented battle buddies, abbreviated and rotating shifts, and frequent breaks into our redeployment plan. Time away from the hospital also helped to alleviate the emotional or psychological stressors that physicians were exposed to. 

It has been shown that in times of national and international disasters, there can be an increased mental health burden on the population 34 City, such as the September 11 th attacks, task forces were assembled for crisis management. Similarly, population-based strategies are currently being employed today. On a more individual level, our department started a "buddy" system, as described previously, at the beginning of the isolation period to ensure active engagement with peers. We also established connections with our departments of psychology and psychiatry for individuals to engage with mental health support as needed.

Engagement of faculty with meetings arranged through teleconference platforms was implemented early on to maintain education and peer interaction. Throughout the COVID-19 pandemic, in an effort to maintain resident learning and training, our department has continued all educational conferences by use of teleconference software.

This includes departmental meetings such as the monthly morbidity and mortality conference. The Och Spine Hospital began with Monday and Wednesday morning educational video teleconferences, and maintained our usual Wednesday "huddle" (rotating between research meetings, morbidity and mortality conference, attending meetings and high-risk case conferences). Additionally, we have established a Wednesday morning national educational series among several institutions, and a Thursday evening meeting that is attended by over 200 surgeons worldwide. These allow us to maintain our national and international platform, and garner information from other institutions that are at different stages of the pandemic.

It is important to note that social distancing for healthcare workers also includes distancing within the home. We have recommended that clinicians who are redeployed pack a second set of clothes to change into after doffing the uniform they used to treat the COVID-19 positive patients. They are recommended to then remove those clothes prior to entering their home, sometimes through an accessory entrance if possible, and place everything in a laundry bag to be immediately cleaned. They should then proceed immediately to the shower to decontaminate. It is recommended to use a different bathroom than other occupants in the household. If this is not possible, one should immediately clean the bathroom with disinfectant after use. Surgical masks are donned in the home and social distancing during meals and other interactions should apply. If allowable, one should sleep in a separate part of the house or apartment. Some clinicians prefer housing quarters away from the home although this has not been explicitly recommended by health authorities. Each institution should attempt to provide resources for available housing.

It is well documented that routine physical activity can have a profound impact on both overall health as well as mental wellbeing [36] [37] . This is particularly true when socially isolating and remaining less active at home. Multiple phone and computer applications are available to help stimulate physical activity routines 38 . It is advisable to decrease regular exercise routines to 75% of the prior level of fitness to help stimulate the immune system and avoid paradoxical immunosuppression 39 .

Regular nutrition and hydration are also necessary for optimal performance. Part of the rationale for recommending a shorter duration of shifts is to avoid dehydration or the repeated donning/doffing that would be required over the course of a 12-hour shift to maintain adequate hydration and nutrition. Physicians and surgeons often work continuously without a break in crisis scenarios and busy wards, leading to depletion of glycogen stores and dehydration. If one must work longer shifts, administrators should be sure to have a safe space for doffing and storing PPE for hydration and snack breaks. Additionally, supplying food can help to increase the likelihood that clinicians will eat during a long shift.

While we are hopefully nearing the apex of the curve in New York City, we know from other countries that this pandemic and its devastating effects will continue to roll across the United States in the coming months. We wanted to write this paper to provide some basic guidance, tips and pearls that we have learned as the "tip of the spear" in our country's fight against the pandemic. We recognize that the above recommendations are the product of clinical expertise at a single institution with currently limited knowledge of the COVID-19 pathogen. As such, treatment protocols, resource utilization and deployment strategies are likely to change as more is understood about this disease process and the unique challenges it places on every affected institution.

Looking ahead, we know life will forever be different. Similar to the World Wars and 9/11, these events transform our very fabric of existence. As General McChrystal stated in the foreword, in combating any enemy, an age-old axiom is to "improvise, adapt and overcome." Indeed, the resiliency of the American spirit and those of our healthcare heroes will eventually overcome this invisible enemy.

It will now be up to our country's leadership to prepare for the next catastrophe, pandemic, war or other challenge. We will be better prepared next time, and hope this experience serves to inform hospital systems across the United States and the rest of the world. As George Santayana stated in 1905, and Winston Churchill paraphrased in his speech in 1948, "Those who fail to learn from history are condemned to repeat it." 

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