In this video, anesthesiologist and critical care specialist
Jacob T. Gutsche, MD, discusses how New York Presbyterian prepared to manage their patients with limited resources during the start of COVID-19. He will walk through their thought process when trying to understand what each patient might need, and how they would prepare for the large number of admissions.
@PennMDForum So I just want to thank the uh conference organizers for inviting me. This is uh these types of things are very complicated to put together. Uh And it takes a lot of hard work. So uh thank you. And uh you know, it speaks a lot as you go through this conference and see the people who are speaking uh to Christian, who's on a first name basis with all the uh world's experts uh due to his, you know, outstanding international reputation. So, um I'm gonna talk about the unplanned, uh which is, you know, what, what do we do with uh you know, managing these patients? Uh and the limited resources we have even though we live in the United States. Um and what we were facing at the time and how we dealt with it. Um So just to set the stage of the, this talk and where, where it took place. Um We obviously, we were, we were kind of like the third wave and I or maybe even the fourth, if you look at what happened, China was devastated, then Europe was devastated. Italian um hospitals overwhelmed people who are supposed to be taking care of the patients dying critically ill. Um And then the same thing happened in New York, New York being overwhelmed their outcomes not being very great. And this is what we saw literally coming down the highway towards us. Uh And it was a very scary time. Um, you know, sharing patients who were literally sharing ventilators in uh you know, New York Presbyterian. So and not only that, it was unclear what we were going to be able to do to save patients. Uh It, there didn't, there wasn't a therapy, it was just kind of put them on a support them as best you can and a lot of them will die. Good luck. Um And as was mentioned by the previous speaker, ECMO didn't seem to have any benefit at all. Um And there was a, there was a lot of questions around whether anybody should go on ECMO or even a ventilator for that matter. Um So that drove some of the resource management particularly when you have a hospital that is strained with beds and staff. So the question was, should we even be using this technology at all? Um And this question rose to the highest levels of the people in the in the uh health system, uh which I had to have quite a number of phone calls with in the beginning of us starting to get these types of patients and calls of. Should we even be putting these people on and how are we gonna manage that? And this is what we were facing internally. The question was, how are we gonna handle this with our current resources? And these were projections put together by data scientists based on the ability of our local population to deal with reducing their social contact. That means wearing masks, not going out, not coughing on each other. Um which as we know, Americans are challenged with these types of things um and continue to, you know, fight this. So this was the predictions for where we would be in our hospital for volumes given the fact that there would be, you know, not a ton of uh social contact reduction. So uh we were trying to look at these and figure out days where we would run out of resources. When would we be putting the last patient on a ventilator? When would our last hospital bed be filled? When would the our capacity based on maximum nursing availability to staff these spaces? And so that, that breaks our resources and, and we thought about this and I'll go over this again and again is breaking. What, how do we simplify what we need into spat space? Where are we gonna put the patient staff? How are we gonna have somebody take care of them and stuff, which is everything else, equipment, medicines, fluids, ventilators, et cetera. The fourth part, which can dramatically raise or lower your needs is that ambulance that's patients coming into your hospital, from the outside that are already at another institution. And how do you manage that at a place like Penn that gets a lot of our volume from other hospitals that cannot handle what they currently have and send them to us. And that's our culture, that's what we do. Um And how do you manage that in the face of a pandemic with a disease that no one knows how to treat. So, one of the roles I have is uh the associate CMO of critical care across the health system uh for all the hospitals, uh which is, you know, made up of all the medical directors, nursing directors, um you know, lead pharmacists, restorative therapists across the system and figure out problems like this and how we address them. Um and we broke it down very simply as I mentioned, uh space staff and stuff. Um and you'll see as we go into this talk, the staff became the toughest thing to manage. Um As far as how do we keep our hospital staffed? Um One of the things that, you know, within that group, we were working on several different things and one of them was how do we get ventilators into our hospitals? It was clear that we were gonna run out of ventilators uh pretty quickly based on the projections. So we had a group that was looking at how do we manufacture ventilators out of, you know, 3d printers we had local companies that were offering to help us. Luckily, we did not reach that point, but we also had people looking at the estimated shortage. How do we acquire ventilators? There was you and you guys may not have been exposed to this. There was thousands of offers from across the world for ventilators. Uh except a lot of these offers were by scam artists who are ripping off hospitals for millions and millions of dollars. And, and so we would get these vet the ventilator itself. And then administration had to figure out is this a is this somebody who's going to actually send us a ventilator or not? Then we were reviewing, you know, kind of a level two type of ventilator ventilators that are not complex, but they can do at least bipap. So um these are the types of things were going on in the background trying to manage the stuff part of this uh across the health system. Now, I'm I kind of alluded to this in the beginning is Penn has this kind of obligation uh which it is always taken on to be the regional Quinary Center. We take the stuff that nobody else can handle. We are set up staffed and equipped to handle it and that we also are a national and international type hospital. People come from all over to get some of the care we get. But primarily we are, we owe the region. Uh the type of care that we can deliver. So this was being set. Um The stage we'll go into later is what do we do with all these other patients? We're getting request to take care of outside of our region. So staff uh just to focus on the lung rescue part. So we have a mobile team uh in the beginning of the COVID crisis, it was primarily me and the guy in the end, Bill Vernick Emily mckay did some uh of the lifting, but it was primarily two people. So basically every other night on call, um It, it was manageable, then the COVID crisis hit and we're getting 25, 30 calls a day all night. And then we also have a ton of patients we're trying to take care of. So we quickly got exhausted. Uh and we had, you know, outstanding people in the pipeline, Assad and Audrey to help augment the team. And that's how we dealt with a staffing, you know, crisis because I basically had, you know, didn't sleep for six months, that's not really sustainable. So, uh we have an outstanding team and some of them are speaking today. Um So, you know, it, it, that's how we dealt with the E C O side of staffing a lot easier because we have them in the pipeline, a lot harder for bedside nurses. So, and the ones who are able to handle ECMO, they're concentrated in a specific area which is our H V IC US. So how do you take that group and expand them? Because the number of ECMO patients was rapidly expanding. They're teaching people who haven't done E C O in the middle of a pandemic where everyone is afraid to go in the hospital, they're afraid to be exposed to these patients. There's call outs, there are limited access to P pe how do you do that? And uh the solution is simple and this is something you may have heard. Doctors say the questions are complicated. The answers are simple and sometimes and the the answer is simple, train as many people as you can. Um A lot of people like to manage these types of things by concentrating the number of people who can do it to a small group of super users in this setting. You cannot, you have to train as many people as you can. And that's the, you know, simple solution to the staffing. Uh The hard part is getting that training done equipment. Uh We had a limited number of machines, we quickly identified that this was gonna be an issue and asked for as many disposables as possible. This was already had been uh depleted by China, Italy, New York. So we got what we could. Uh But that begged the question. Do we need different platforms? We had two or three at the time. Should we have more? How do you maintain training with that? Um If you do not manage your resources well, or they get exhausted, the government will step in uh as they did in Arizona to say, all right, the ECMO machines are maxed out. So the ventilators are maxed out. These are now your criteria for putting people on ventilators and ECMO machines. We did, we wanted to avoid this. Uh And we were able to luckily in our state. Um And one of the things that helped us with this in establishing criteria, which we're going to later is this regional meeting with which doctor Waldo organized, she organized a higher level meeting across the nation, but a local meeting where we were talking about our experience, what our criteria should be, how should we be sending patients back and forth if needed, if there was limited availability, this was incredibly helpful later as I'll go into, you know, setting a criteria. So pa uh hospitals don't have to shop to find some place they'll take them. We all have the same criteria. Um Space was easy in some ways, ok. Compared to staffing when they shut down surgeries, we had unlimited space when they tried to get surgery back up to speed. That was where it became difficult, but space was never 100%. The limiting factor. We have a tremendous amount of space here. Uh Luckily, and uh we did have discussions about building tents using Lincoln Field as a open air facility, um which we would have done the limitation was staff. OK. And that, that will be the thing for the next pandemic is how are we gonna get, you know, backup staff to come in because that was across the nation, the limiting factor. So the solutions, when resources limit is you have to create criteria. So we didn't do that for the ventilators, but we certainly did it for the ECMO machine. And also the concept of time, limited trials became more apparently uh needed. So PREO COVID were pretty loose. Uh you know, we had up to, you know, age 70 if you were, you know, healthy uh B M I, less than 55 we had some people over that vent duration, less than equal to 10 days and they had to demonstrate they needed ECMO. But that became clear that that was if we put every 70 year old on who needed uh ECMO, we would have flooded, we could have filled the hospital. So with the working with the senior leaders health system, they wanted something they could apply not only to us, but to the circumstances for cardiac surgery and other things that would create tears where we would say, ok, patients, tier one, they meet, you know, these lower level criteria um age 50 no comorbidities on event for a short duration, a high likelihood of survival. Uh and this is based on the fact that you have a certain amount of capacity and then a tier two, which is patients a little bit older, maybe more, some COMD if you have the capacity. Um This was something that was floated early on and accepted, but it quickly evolved. And this is because we were getting a tremendous amount of calls from the New York area that was overwhelmed. And as I said, we had an obligation to our region. Uh and the health system said we cannot fill our hospitals with patients from New York. And then a week later when we have all the calls from Philadelphia say no. So this uh created some uh you know, thanks to Christian's work in borrowing some things from Pittsburgh, a basically based on levels of how much capacity you have for equipment of rolling criteria that is based on, if you have a lot of uh uh space staff and stuff, you can be a little bit more liberal with your uh inclusion criteria as that diminishes, you have to be more picky. Um And so we landed on this uh and this aligned with lung transplant criteria. So this is very stingy. Uh It's, you know, basically, essentially young people like I wouldn't qualify now, which is uh a bummer. Um So, you know, relatively skinny by our Philadelphia standards and uh no renal failure, pneumo Orne Stines. Uh So we wanted people had a good chance for survival and if they didn't, they could get a lung transplant. Um And we still had a large volume of patients going on ECMO. Uh So that is part of how we managed, not having to get overwhelmed with our space staff and stuff with ECMO. The other thing we did was augment our development of time limited trials. So a patient goes on ECMO before you even start, you've got to figure out how long are we gonna offer this for, for patients? Um The problem is nobody knows what the right answer for. This is very ethically sticky. It's very challenging to do. And it takes uh a lot of for intestinal fortitude to sit down with the family and say we're going to stop this for your family, they're not going to survive because as you could see, often these were men breadwinners for their families with young kids. That's, that's hard. So what we did is we made it part of the consent um weekly review was held by the team after a certain point to say, remind the family of what this this looked like from a duration standpoint, whether they would survive or not based on the expert opinion of the group. Um and involving ethics and palliative care in the city, in the state of Pennsylvania. You are not obligated as a medical facility or physician to offer care that will not improve the chances of the patient leaving the hospital. Uh this is hard, but when you have, you're getting 25 calls a day from people who seem like candidates and the participation who by all accounts is not gonna make it your that's your obligation to, to manage your resources. So in summary, resource management is crucial during a pandemic. Uh not only during but before uh staff, staff support is paramount that was our biggest factor. Uh And it will be in the future. This will, this is a big lesson learned and then selection criteria and time limited trials can help control volumes. Thank you.