Volunteerism, Tiered Critical Care Teams During COVID-19

Meghan Lewis, MD

Not all institutions—as Craig Coopersmith, MD, told HCPLive® last week—do not currently have a resource or staffing issue due to the coronavirus (COVID-19). At least not yet. What Coopersmith and many other experts are stressing is an absolutely efficient strategy to best utilize both healthcare personnel and the very limited intensive care unit (ICU) tools necessary for reduced spread and severity.

Some institutions have begun recruiting unexpected personnel to the front lines of care when implementing strategies to this point.

In an interview with HCPLive, Meghan Lewis, MD, surgical critical care specialist at Keck Medicine of USC, discussed how surgical residents have volunteered themselves into their tiered critical response teams, how medically ill patients are being valued during the pandemic response, and what lessons can be learned from initial COVID-19 response.

HCPLive: How is your institution managing COVID-19 care and response right now? What is the care team?

Lewis: Our department is the acute care surgery department for the University of Southern California. We do the emergency surgical services and critical care surgical services for both the Keck hospital and for Los Angeles County. We're an academic department, so we have staff, surgeons, physicians, and we also have fellows and residents under us who are still completing their surgical and critical care training.

So, we expect to be very heavily involved in the response to this pandemic. The residents who are still in their training have been getting very eager to learn what their role is going to be in how they can contribute during this time.

HCPLive: What does that role look like, for the residents? How much training has had to be expedited?

Lewis: The residents that I'm talking about for our department are surgical residents. And COVID-19 is causing pneumonias. In severe cases, people end up in the ICU with critical pneumonias, requiring mechanical ventilation, requiring intense medical therapy. So, this is a little bit outside of the training that general surgery residents get during residency.

The general surgery residents are probably not the main workforce that would be called up to support in this time. But, there's a lot of crossover between what they have learned during their training and the knowledge base that they formed—and it could be useful if added to care teams, where they support critical care nurses and physicians in their jobs.

And so that's what we've encouraged them to do, is to think about this as a model where we'll have a team of doctors and nurses taking care of a number of patients, and we'll divide the responsibilities appropriately based on what they can do, what they do know, and all working together as a team.

HCPLive: Were there any previous models or instances that you used as groundwork or foundation for establishing this quick and emergent-prepared strategy?

Lewis: The Society of Critical Care Medicine (SCCM) does describe some disaster models or search models for augmenting critical care teams when there's an increased need such as this. And they described a tiered model, where you have the person with the training that's most critical—such as the staff intensivist—at the top of the tier. And then they form these multiple teams.

The teams have to have at least one person with the expertise for each aspect of care. So, that could be a critical care nurse, a respiratory therapist, and a pharmacist, and all the people that are always needed for the care of those patients.

But the ratio is not going to be the same as it would be during typical care. So typically, a critical care nurse can really only do critical care nursing for 2 patients at time. But in a time like this, they might be assigned 6 patients. And so, they become a manager of the critical care nursing for those 6 patients—they're going to continue to do the most critical aspects of the nursing for those patients. But they're going to assign some of their typical duties to another provider who isn't usually involved in the care of critically ill patients.

So, this is where the residents fill in; they might not usually be a part of that care of critically ill patients with severe pneumonia. But now, because they are capable of drawing blood, capable of starting IV lines, capable of administering medications and adjusting infusions, they become a part of the team. They're added to the team, and they will augment the critical care nurse in his or her role.

HCPLive: A discussion we recently had with an SCCM expert explained how potential resourcing issues during COVID-19 response may be driven by staffing issues—if the responding team isn't knowledgeable enough to efficiently use the limited resources, the reach of care will be affected. Is that an issue your team has seen at USC?

Lewis: Yes, for sure. I think, at the moment, we have all the resources that we need. But I think a large part of it is a preparedness for how we will tackle this if and when we don't have the resources we need. And again, it's being mindful that these are not infinite resources, and we need to use everything we have as smartly as we can.

For example, nurses are not an infinite resource, and we don't want them to burn out, and we don't want them to get sick. This is something where is everybody does their share, everybody does their part, then we can distribute the work more evenly.

HCPLive: A lot is made of the patients that will be coming to the ICU or hospital with COVID-19 concerns, and their risk of being infected then—and understanding why people should be cognizant of the symptoms. Can you speak to caring for medically-ill patients who were already hospitalized during the start of this response?

Lewis: I think I would echo what our leaders have said about if it's not something you have to have care for right now, then you should delay. But for those people who do have urgent needs, I would reassure them that, as healthcare providers, we have their very best interests in mind. We are setting up schedules and units to keep in mind isolation of patients who could be infected—protecting our providers for their sake, but also for the sake of our other patients.

We make sure that everybody is educated about how to don this personal protective equipment (PPE), how to remove it, and making sure that you're not carrying anything with you when you go on to do other patient care.

HCPLive: A lot of this is changing our perspective and understanding of how we're set up to respond to pandemics. What do you imagine will be the takeaway message down the road, in terms of healthcare response and preparedness, that we could learn from COVID-19?

Lewis: I think that you can't be too prepared. I think all hospitals and us included have disaster preparedness plans, and they have to be updated quite regularly, and have to be drilled. And I think when something like this happens, it really nails home that's the reason for what seems like a bunch of extra work—in the form of writing these plans and drilling these possibilities.

When it comes, you can't be too prepared.

HCPLive: Is there anything else you'd want to add?

Lewis: I would just comment that what the general surgery residents have done—largely on their own accord, and what they actually were eager and excited to do—is, in a lot of ways, inspirational to me. I think that they've stepped up to the challenge and said, 'What's going to be our role? Where do we fit in? How can we help?'

And I'm hearing that from a lot of providers and from a lot of people outside of the hospital—just echoing this response of, 'What can be my role? How can I help? Can I make masks?' And I think that we should all be inspired by people responding that way.