key: cord-0710258-ks8caxqj
authors: Stylianos, Steven; Mesa-Jonassen, Amy E.; Albanese, Craig T.; Bacha, Emile A.; Stark, Natalya; Guida, Sarah Jane; Goffman, Dena; Saiman, Lisa; Kernie, Steven G.; Lalwani, Anil K.; Cassai, Mary; Sun, Lena S.
title: The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City
date: 2020-05-22
journal: Ann Surg
DOI: 10.1097/sla.0000000000004104
sha: ef0eb6b68822ee4024acf959d2d00bac4739c5c6
doc_id: 710258
cord_uid: ks8caxqj

nan

I n March, 2020, New York City (NYC) and the surrounding boroughs and counties became an epicenter of COVID-19 infections with a rapid rise in critically ill and ventilated adult patients, many of whom were treated in NewYork Presbyterian (NYP) system hospitals. Surge capacity strategies were rapidly employed, more than doubling intensive care unit (ICU) capacity in NYP facilities. In the face of accelerating numbers of COVID-19 admissions, and impending critical shortages of personal protective equipment (PPE), ICU beds, and ventilators, NYP made the decision to halt all elective surgery across its campuses with only the most emergent and urgent cases allowed.

The Morgan Stanley Children's Hospital (MSCH) is a quaternary 284 bed facility located in the Washington Heights neighborhood of NYC. It is freestanding by virtue of its separate buildings but is part of a large 10 campus health care system. It is the only hospital dedicated solely to pediatric and obstetrical care within the NYP system and in NYC.

This report documents the many swift changes made within the first weeks of the NYC pandemic by MSCH perioperative services to facilitate our entire health system's response to a massive influx of critically ill adult patients, and to care for the COVID-19 positive children at MSCH. 1, 2 Table 1 summarizes the changes in roles, processes, and facilities at MSCH. In addition, we outline processes used to expand Operating Room (OR) activities for semiurgent (time-sensitive) patients while the ban on elective surgery was still in effect. The new pediatric COVID-related multisystem inflammatory syndrome is briefly described.

Because many COVID-19 patients require intubation, it was critical to have the most experienced provider(s) performing this high risk aerosol-generating procedure. Thus, the Division of Pediatric Anesthesiology created a 24 h/7 d dedicated airway management team for all pediatric and young adult patients. The on-site team consisted of 1 pediatric anesthesia faculty member and a pediatric anesthesia fellow. For all intubations, the airway team carried a ''COVID airway backpack'' with PPE and all necessary supplies for intubation in COVID-positive or suspected patients.

As the COVID-positive patient cohort surged in NYC, the ORs at the adult hospital of the NYP-Columbia University campus were repurposed to care for critically ill adult COVID-positive patients requiring mechanical ventilation (OR-ICU). Three pediatric anesthesiology faculty and 3 of the 6 pediatric general surgery faculty redeployed to serve on the adult critical care teams caring for patients in the newly created 78 OR-ICU beds that reside in the adult hospital that is across the street from MSCH.

Pediatric general surgery faculty also took multiple shifts as attendings for the novel surgical workforce activation teams, a combination of acute care surgery and procedure-focused (ie, venous and arterial access, chest tube insertion) response teams. These teams included surgical housestaff.

Beginning March 17th and continuing for the next 6 weeks, an average of 16 MSCH OR staff ($60% of a daily MSCH perioperative services team) were redeployed each day and night shift to care for the adult patient surge in the OR-ICU and at other NYP facilities. This daily infusion of our skilled nurses and support staff to care for adult patients was instrumental in maintaining adequate patient care ratios in the OR-ICU. The children's hospital redeployed nursing and support staff members have provided more than 700 work-shifts in adult care areas over 6 weeks. Additional OR staff were redeployed to the pediatric ICU and Labor & Delivery units which were operating at full census.

At the inception of the OR-ICU in our adult hospital, all of the frontline health care providers consisted entirely of providers from the Department of Anesthesiology. They included anesthesiology faculty, anesthesiology fellows from various subspecialties, and large number of anesthesiology residents and Certified Registered Nurse Anesthetists (CRNAs). During normal operations in our pediatric ORs before the COVID pandemic, 5 CRNAs and 9 residents were assigned to the children's hospital. During the COVID pandemic period, we redeployed 2 CRNAs and all 9 anesthesia residents to staff the adult OR-ICU. To staff the pediatric ORs and non-OR procedural areas during this period, anesthesiology staffing consisted of 2 CRNAs, and 2 fellows, and all available anesthesiology faculty.

In the adult OR-ICU, anesthesia machines needed to be used as ventilators for COVID patients. A total of 23 adult ORs were

As the first COVID-19 positive patients began populating the children's hospital, the need for a negative pressure room within the operating suite was recognized. This room would provide a means to safely access the airway in COVID-19 positive patients coming for surgery, and provide a location to perform other aerosol generating procedures such as bronchoscopy, tracheostomy, emergent otolaryngology surgery, and endoscopy, regardless of COVID-19 status. Our facilities team recommended using a room at the end of the corridor with nearest access to a window for ease of installation. Overnight, the team placed a negative pressure High-Efficiency Particulate Air (HEPA)-filtered venting system and ran temporary ductwork across the ceiling and out through the wall towards the window that was isolated by sealed heavy plastic sheeting.

To minimize the risk of viral transmission between patients, 1 operating room was designated for major surgical procedures in known COVID-19 positive patients. This room was emptied of all but the most basic of equipment and goods. A designated ''runner'' was available outside the room to procure any goods or equipment that might be needed during the case and a nearby, unused operating room was stocked with additional OR and anesthesia supplies. All anesthesia machines throughout the OR were fitted with HEPA-filters on the expiratory limb of the circuits. We found that placement of the filter closer to the endotracheal tube in infants resulted in unacceptable levels of dead space ventilation and excessive CO 2 retention. The anesthesia machine, monitors, and computer screens and keyboards were all draped in thin disposable plastic sheeting. The anesthesia workstation, containing equipment, and medications, was similarly draped and all efforts were made to remove the necessary items for the case before patient entry. The goal was to avoid entering the machine during the case, potentially contaminating all contents. Postoperatively, patients were transported to negative pressure rooms either in the ICU or postanesthesia care unit (PACU). The endotracheal tube was clamped before transfer to a HEPA-filtered ambu-bag or portable transport ventilator for ICU bound patients. Intubated neonatal patients were transported from their ICU to the OR using their neonatal ventilators, thus obviating the need to disconnect the closed system which would aerosolize gases and potentially contaminate the environment.

An ongoing surge of COVID-19 patients was occurring at 1 of our neighboring NYP hospitals. They needed to create additional surge beds for COVID-19 positive patients using their postpartum beds. To do this, they would need a place to decant their obstetric and neonatal patients as there were no candidate places on-site. MSCH was the best place to move these patients as both locations shared a common faculty from the Department of Obstetrics and Gynecology at Columbia University.

Initial steps were taken to safely transfer inpatient postpartum mother and newborn dyads in an effort to vacate the postpartum unit on April 4, 2020 whereas planning was quickly undertaken to be able to consolidate all obstetric services (eg, triage and Labors & Delivery) at MSCH. We recognized that to assume the volume we would need additional space to safely accomplish this goal. Multidisciplinary discussions were held and the option of caring for low risk, COVID negative patients scheduled for cesarean deliveries in the MSCH perioperative areas was explored.

Ultimately, 1 general surgery operating room and 2 PACU bays at MSCH were dedicated to Obstetrics and equipped with fetal monitors, newborn equipment, and all necessary instruments and supplies. This was in addition to the 3 Obstetrics (OB) ORs and 4 PACU bays on the existing labor unit. The referring OB service closed on April 9. Small teams were maintained there for obstetric or gynecologic emergencies. Beginning on April 9, we performed 1 scheduled cesarean delivery in the dedicated pediatric operating room. Between April 10 and May 8, 33 C-section deliveries were performed in the MSCH OR in the first 2 weeks of activity with healthy outcomes for moms and newborns. This helped to facilitate safe care for these patients whereas allowing continued safe operations on our busy labor and delivery unit.

The reverse transcription polymerase chain reaction test for the qualitative detection of nucleic acid from Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in nasopharyngeal swabs was performed using Cepheid technology which provides results within 1 hour. We initiated same-day SARS-CoV-2 testing in the perioperative area in an effort to maximize safety and reduce patient and family stress. By implementing same-day testing, patients and families avoided potential exposures of additional travel and visits to the hospital for testing. Beginning April 8, MSCH perioperative services initiated rapid reverse transcription polymerase chain reaction swabbing on all outpatients, same day admits, and inpatients so that all patients had testing within 24-hour of their procedure when clinical urgency allowed. Our trained perioperative nurses performed the test using full PPE precautions. Swab samples were processed in real-time and not batched. Although waiting for test results, the patient and family stayed in their designated partitioned bay.

During the moratorium on elective procedures, we performed 303 pediatric subspecialty surgical procedures from March 17 to May 8, 2020 (Table 2) , a 77% reduction in surgical volume at MSCH compared to the same interval in 2018 and 2019. In addition, 49 neonatal and pediatric cardiac catheterization procedures and 99 pediatric interventional radiology procedures were performed during the same time period. Of note, because MSCH is the only American College of Surgeons-designated level I pediatric trauma center in NYC, we staffed and kept open and ready 1 OR for emergencies.

Emergency procedures were reviewed by MSCH's surgeonin-chief and chief of pediatric anesthesiology. All urgent (within 48 hours) procedure requests were reviewed by a larger multi-disciplinary committee with rapid turnaround to facilitate scheduling and resource planning.

Given the historical high volume of extremely complex pediatric cardiac surgery at MSCH, these cases required special attention and were initially prioritized by the chief of pediatric cardiac surgery based on the following:

(1) clinical status of the patient and risk of delaying surgery, (2) resource-utilization, such as anticipated ventilator duration, ICU stay, blood product usage, perfusion needs, (3) risk of exposure for the patient, family, and healthcare staff, (4) co-morbidities and complexity of the procedure with implications on the usage of hospital resources, (5) the safety of the patient's social and clinical situation if surgery is delayed. 3 Subsequently, the candidate cardiac patients were reviewed by aforementioned multi-disciplinary committee. Patients were labeled as urgent (category I) if they were at risk of dying or serious harm without surgical repair within 24-48 hours. Semi-urgent cases were those that needed to be done within 2 weeks (category II). In-house patients who could not be discharged without surgery, Status IA transplants and neonates with ductal-dependent lesions were also labeled as urgent.

For the 7-week period from March 17 to May 8, 2020, the pediatric cardiac surgery service performed the second highest number of surgeries, 71 (Table 3) . Forty in-patients (category I) had cardiac repairs, of which 22 were neonates. Another 17 patients in category II had open heart surgery during that time period as well. Some patients were admitted from home such as those with a tetralogy of Fallot lesion with very high right ventricular outflow tract gradients, Blalock-Taussig shunt-dependent patients with increasing cyanosis, and complete atrioventricular canal patients with severe failure to thrive despite maximal medical therapy. One heart transplantation was performed on a patient while supported on Extracorporeal Membrane Oxygenation (ECMO). Several babies with congenital heart defects were born during this period from COVID-positive mothers. Of those who required surgery, none tested positive for COVID-19.

During the 6 weeks covered by this report, the highest number of procedures (85) was performed by the pediatric general surgery service ( Table 4 ). The majority of children with acute appendicitis presented to the hospital with signs and symptoms of perforated appendicitis and most had interval treatment. Patients meeting criteria for early acute appendicitis were treated with surgery if COVID-19 negative and IV/ oral antibiotics if COVID-19 positive. To minimize the escape of potential aerosolized particles from laparoscopy, we implemented the use of closed-circuit devices that filter the released carbon dioxide, 

Once we were confidently on the downslope of COVID-19 infections, plans began to ''slowly open the aperture'' and address the patients who had their surgical treatment postponed during the pandemic. These patients did not fall into the emergency/urgent category that received care during the entirety of the pandemic but were deemed semi-urgent. They were not; however, elective cases. Our aim was to weigh individual patient benefits and risks against the ongoing public health concerns. All pediatric surgical and medical subspecialists who treat patients in the MSCH OR submitted prioritized case logs to an internal NYP perioperative leadership group. In addition, pediatric subspecialty surgeons from other NYP hospitals also submitted their cases as all pediatric care continued to be provided solely at MSCH. Factors that influenced prioritization included treatment of patients with proven or suspected malignancies, alleviation of pain, improvement of function and quality of life, and prevention of potentially serious complications or disease progression. Of the 727 postponed patients, 89 (12.2%) were scored as semi-urgent (needing to be performed within 2 weeks of increased OR activity).

Operating room block time was assigned to subspecialty services based on several factors: (1) Number of semi-urgent cases (those needing to be performed within 2 weeks of increased OR activity) on their log; (2) pre-COVID allocation of OR blocks; and (3) pre-COVID utilization data. During the first week of expanded activity, we utilized 6 of our 10 main ORs; 4 rooms were block scheduled, 1 room was ''open time'' used at the discretion of the perioperative leadership committee for unassigned services, 1 room used for emergency and add-on cases (Table 5) . We assigned block time in 2 rooms on both Saturday and Sunday to further facilitate reducing the queues. One of 2 Endoscopy suite rooms were also re-opened. This plan allowed the Obstetrics service to continue using the MSCH OR for overflow Csections and maintained an additional MSCH OR as a negative pressure room for aerosol-generating procedures and 1 room was reserved for known COVID-positive patients needing major surgery.

During the first 6 days of expanded activity, 48 (53.9%) of the 89 semi-urgent procedures were completed. All procedures were vetted by the MSCH OR leadership group. No procedures deemed purely elective were performed during this interval. Valuable information was gathered during this expanded schedule regarding optimal patient throughput, COVID testing, social distancing in perioperative waiting areas, environmental services, and PPE. Rapid assimilation of new processes and infrastructure adjustments, influenced by the pandemic, should allow return to our full 10 room main OR and 2 endoscopy suite capabilities in the near future. Monitoring for COVID recrudescence and regulatory guidance will be required for all elective surgery to resume.

Acute COVID-19 in children has been less severe than in adults. However, on April 27, 2020 clinicians in the United Kingdom reported the emergence of a COVID-related multisystem inflammatory syndrome (CMIS). Since then, physicians at MSCH and other children's centers have noted patients from infancy to adolescence admitted with 

NYP's 10 hospital health care system flexed rapidly and aggressively to meet the surge of critically-ill, ventilated COVID-19 positive adult patients. All elective procedure were postponed and adult ICU capacity was more than doubled within days. The children's hospital aided this effort by becoming the sole provider of pediatric care in the health system freeing pediatric beds for adult patients. The children's hospital supplied equipment (anesthesia machines), redeployed personnel (faculty, residents, nurses, staff), and created process and facilities to safely support the care of children with COVID-19. This report captures specific steps taken by perioperative leadership to best utilize the children's operating rooms in the overall strategy against the pandemic whereas maintain a safe environment (for staff and patients) for emergency, urgent, and time-sensitive operative procedures. In addition, processes were developed which facilitated initial expansion of OR activities.

Epidemiology, clinical features and disease severity of COVID-19 hospitalizations at a children's hospital in New York City

Universal screening for SARS-CoV-2 in women admitted for delivery

COVID-19: crisis management in congenital heart surgery

Understanding the ''scope'' of the problem: why laparoscopy is considered safe during the COVID-19 pandemic