The Quiet Heroes of COVID-19

COVID-19 has changed the priorities and outlook of individuals, groups, and organizations. Situated in the heart of Indiana, Indiana University Health (IUH) has not been immune to the impact. IUH Academic Health Center (AHC) hosts the tertiary referral center for the system and the state. We were tasked to be prepared as an epicenter for the surge and to help develop best practices to safeguard the health of our workforce and improve efficiency.

Indiana University Health consists of several facilities across the state of Indiana. The IUH system has more than 2700 beds and an army of more than 450 respiratory therapists who worked tirelessly to provide essential respiratory care services.

Maintaining Open Airways – Oil up the Machines

News on lack of available ventilators was at the center of our concerns and was placed on the leadership radar early in COVID-19 course. Supply chain decisions to provide for equipment requirement to meet local-regional surges were put in place and revised on a frequent basis, based on the need of the hour.

We obtained total ventilator counts from our system partners - sorted by brand and by type – high acuity, low acuity, transport, heated high flow, and BiPAP devices. This count was noted on a spreadsheet which could track every piece of equipment across the state. Similar brands of ventilator were cohorted at facilities to minimize practice variations.

In the AHC, ventilator use was reviewed graphically to provide usage trends. Algorithm and thresholds for recruiting the next set of ventilators were defined, based on availability and potential overlap. Threshold of 80 percent ventilator use was kept to introduce the second line/ third line treatment interventions and variations. This threshold was decided, based on guidance from the system leadership. Noninvasive ventilator devices use for invasive ventilation was considered a real possibility and was the next intervention needed if the ventilator usage crossed 80 percent threshold. We also realigned the use of transport ventilators to be used in low acuity situations, as needed.

Recruiting the Alveoli – All hands-on Deck

Staffing of physicians, respiratory care, nursing, and support staff was optimized by minimizing elective patient interventions. Decreasing elective procedures reduced our inpatient and outpatient load and allowed personnel availability for redistribution, to substitute sick/quarantined workforce, and to manage the surge. Orientation plans were developed for the reassigned workforce. Standardized workflows were established for the respiratory therapists, allowing for streamlined and efficient onboarding.

IUH System Command Center started rolling conversions of multiple adult progressive care units (PCU), closed units (previously unused), and the Methodist level III nursery to adult ICU capabilities, effectively doubling our ICU beds (170+ at baseline). The executive order issued by the governor of Indiana provided an additional stream of recently graduated students from medical school and respiratory therapy colleges.

Dedicated procedural teams, consisting of an anesthesiologist and a respiratory therapist, were created to perform intubations, central lines, and percutaneous arterial catheter placements. Procedural teams provided a consistency in interventions. This allowed for mastery of donning and doffing and critical care procedural interventions and resulted in conservation of PPE.

Connection to the Brain – Coordination and efficiency

Changes to practice and new devices occurred quickly and daily in the day and age of COVID-19.  Practice patterns changed based on success and failure experiences, innovations, efficient practice identification, and infection prevention guidelines. Education material for the workforce was developed pre-emptively, based on the trends noted and possible interventions needed.

The mammoth task of providing quality education material, alongside valuing the workforce and patient safety, was undertaken by the respiratory care education team. All educational materials were posted on an on-line, shared platform; questions and concerns were voiced and discussed during huddles and staff rounds. The dispersion of medical education and workflow changes for the therapists and the critical care providers was undertaken by the medical director for the respiratory care department. Bedside troubleshooting, over the shoulder mentoring, was the key to maintaining the workforce morale and confidence.

Direct, consistent, and timely communication for front line team-members instilled confidence and trust. Education and information materials were updated based on the evolving literature on COVID-19.

Change in an organization, system, or team level is always anxiety generating. Approach to COVID-19 was associated with changes at an unsurpassable level. Daily and shift-based huddles, done for the front-line workforce, became the lifeline for change education, key updates, and practice variations. Time bound projects were initiated in the huddles and reported back in the consecutive huddles. Questions and concerns were addressed to satisfaction for the frontline workforce in less than 24 hours in almost all occasions.

Innovation – Thinking Outside the BOX

Invention and innovation were at their peak during the initial days of COVID-19 surge. We worked on improving efficiency and reducing waste. Team members were tasked with ideas to innovate, based on their area of expertise. New ideas were vetted at the director huddle and then presented to the infection prevention group. Once approved at these two levels, they were then sent out as education material to all stakeholders.

Examples are noted below:

Filter drying process: The supply of expiratory filters was limited during the surge of COVID patients. Equipment coordinators experimented and lab-tested a process for drying the expiratory filters by connecting to the suction supply in the room. This innovation allowed us to reuse filters on the same patient, once the drying process was complete. The process allowed us to conserve available supplies until our warehouse supply returned to a 30-day minimum. 

Independent monitoring of two patients on one ventilator (ventilator share/ split technology): Rajat Kapoor, MD, medical director for respiratory care, and Tobin Greensweig, MD, critical care fellow, collaborated with Purdue University engineers to identify a safe way to ventilate two patients on one ventilator. With use of locally available computer mother boards, 3-D printed connection devices, and various flow and pressure sensors, we developed a successful ventilator share prototype. This prototype was approved by clinical engineering and IU health system leadership. The final product was then showcased within the pulmonary and critical care group and was approved for use, if needed, on emergency bases. This technology was not used in real time in our patient population.

We are part of a big, complicated system, but we managed to keep open, respectful communications, sharing the best of ourselves in a difficult time. Having the experience of those before us, relying on in-house expertise, and blessed with a dedicated team, kept us strong and connected for the many months of surges followed by the calm yet to come. 

References:

1. Kapoor R, Poole T, Bate C, Strock J, Spencer B, Fulmer W: COVID-19: On the Front Lines in Indiana. Pulmonary Press. Indiana Society for Respiratory Care. Volume VI, Issue 2, July 2020.

I want to recognize several people for their help and support during planning of projects and guidelines:

Vicky Strock, BA, RRT, Manager, Quality and Equipment
Joel Meacham, BS, RRT, Education Coordinator, AHC, IU Health
Cheri Bate, MA, RRT
Tammy Poole, MS, RRT-NPS, Director, IU Health Methodist Respiratory Care
Parveen Chand, MHA, Adult AHC Chief Operating Officer
Chris Weaver, MD, MBA, Senior Vice President Clinical Effectiveness
Mark Luetkemeyer, MD, Adult AHC Chief Medical Officer
Scott Roberts, MD, Service Line Leadership, Pulmonary and Critical Care Division
Todd Stanley, MBA, RT, CRA, Vice President Clinical Operations
Patricia Ingle, MS, RRT, Executive Director AHC Respiratory Care

Rajat Kapoor, MD, MBA
Assistant Professor of Clinical Medicine, Pulmonary and Critical Care
Respiratory Care Medical Director
Academic Health Center, Indiana University Health