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Critical Care Medicine ; 49(1 SUPPL 1):49, 2021.
Article in English | EMBASE | ID: covidwho-1193816


INTRODUCTION: In early March 2020, COVID-19 spread in New York City. This paper shows trends of rising cases of DKA associated with a worsening COVID-19 pandemic in New York City. With the potential for such a large number of DKA patients, our institution found a need for revised glycemic management protocol. We discuss how a multidisciplinary team designed a protocol to care for patients with COVID-19 infection and DKA. METHODS: Five of The Mount Sinai Health System's EDs are on a shared electronic health record system (Epic Systems, Verona, WI). Deidentified visit data extracted for routine quality review was made available for analysis. We looked at total visits and select visit diagnoses related to DKA through March, April and May 2019 and compared those counts to the same period in 2020. Our protocol was developed by stakeholders in a multidisciplinary hospital team. We focused on the basic tenets of DKA management: insulin therapy, fluid resuscitation, and electrolyte repletion. RESULTS: A total of 93,218 visits were recorded across the five EDs from March 1-May 31, 2019. During that period there were 106 diagnoses of DKA made in the EDs (0.114% of visits). Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0.363% of visits). This coincides with the height of the Sars-CoV-2 pandemic in New York City. To address this surge, our protocol decreased the frequency of fingerstick monitoring, with changes to insulin dosing allowing admission to non-ICU beds. We transitioned from a provider-driven protocol to a nurse-driven protocol to avoid treatment delays due to order placement. Insulin infusion rate charts were created to provide nurses guidance on dosing modifications. To minimize ARDS risk, our protocol's fluid replacement recommendations lowered resuscitation and replacement rate volumes, adjusting based on provider reassessment. Lab values were monitored every 3-4 hours. CONCLUSIONS: There is a correlation between the rise of the Sars-CoV-2 pandemic in New York City and a net rise in patients diagnosed with diabetic ketoacidosis. We believe our DKA protocol will facilitate safe and effective management of patients with COVID-19 and DKA, reducing the healthcare burden associated with protocols that necessitate frequent treatment modifications and ICU-level care.

Critical Care Medicine ; 49(1 SUPPL 1):42, 2021.
Article in English | EMBASE | ID: covidwho-1193803


INTRODUCTION: COVID-19 2020 pandemic with New York City (NYC) as the epicenter necessitated an unprecedented increase in critical care capacity and development of institutional guidelines for care. We describe our drastic increased ICU capacity and how we created and disseminated our guidelines. We hope our experiences help others manage their COVID-19 peaks. METHODS: Mount Sinai Hospital System includes a medical school and eight campuses, the largest being Mount Sinai Hospital (MSH). Since 2013, MSH had system-wide staffing models, cross credentialed staff, and combined leadership. MSH has and Institute for Critical Care Medicine (ICCM) that includes seven adult ICUs, 45 critical care faculty, rapid response team (RRT), vascular access team (VAS), difficult airway team (DART), patient safety quality team (PSQ), clinical research team, and post-ICU recovery clinic. ICCM coordinated COVID-19 critical care response within MSHS. ICCM, Emergency Medicine, Anesthesiology, and Infection Prevention helped develop systemwide guidelines on our COVID-19 website accessible to all hospital employees. RESULTS: MSH expanded from 1139-beds, 104 ICU beds, to 1453 beds, 235 ICU beds during the COVID-19 peak. CONCLUSIONS: MSH's response to COVID-19 surge by expanding critical care bed capacity from 104 to over 200 ICU beds required teamwork across disciplines. We developed new guidelines for airway management, cardiac arrest, anticoagulation, vascular access, and proning that helped streamline workflow and accommodate the surge in critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units by leveraging a tiered staffing model. This approach to rapidly expanding bed availability and staffing across the system was made possible by the collaboration between ICCM, emergency department, anesthesia department, and infection prevention, and helped to provide the best care for our patients and saved lives.

Chest ; 158(4):A598, 2020.
Article in English | EMBASE | ID: covidwho-860867


SESSION TITLE: Lessons from the ICU: What have We Learned about the Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Benefits of early tracheostomy (2-10 days after intubation) include decreased sedation, days on ventilator, ICU length of stay and long-term mortality. In addition, it helps improve patient’s comfort level, tracheal suctioning, oral hygiene and facilitates early mobility in comparison to delayed tracheostomy (7-14 days after intubation). With the recent COVID-19 pandemic, an unprecedented surge in patients requiring prolonged mechanical ventilation led to an increase in the need for tracheostomies. Tracheostomy is an aerosol-generating procedure that raises potential risk to the proceduralists. Therefore, international professional otolaryngology and surgical organizations published guidelines, which recommended delaying tracheostomy to after 21 intubation days in order to ensure viral clearance prior to the procedure. In the setting of these well-intended practice guidelines, intensivists are faced with a new dilemma;following the standard of care for tracheostomy planning vs. delaying the procedure without evidence to support the new recommended guidelines. METHODS: We utilized our previously established Institute for Critical Care Medicine Tracheostomy Team (ICCM-TT), with its multidisciplinary departments, which include Critical Care, General Surgery, Cardiac and Thoracic Surgery and Otolaryngology. In April 2020, throughout the nine ICUs dedicated to the management of COVID-19 patients, the ICCM-TT performed 111 tracheostomy procedures. Case selection involved a multidisciplinary team evaluation of patient’s clinical status and wishes after goals of care discussion. Median time from translaryngeal intubation to tracheostomy was 11 days. All cases were performed at bedside, using percutaneous dilatational technique with bronchoscopic guidance. Additionally, real-time ultrasound guidance was utilized in cases identified to have difficult anatomical landmarks. All of the 111 procedures were performed within 1 day of the tracheostomy request, unless medical instability deferred the procedure or revisiting goals of care was needed. RESULTS: Of the patients who received tracheostomy for COVID-19 prolonged respiratory failure: 35 (31.5 %) patients discharged home alive, 23 (20.7 %) weaned from mechanical ventilation (no ventilator support, downsized or decannulated) but remain hospitalized on non-ICU floors, 33 (29.7 %) expired and the remaining 20 (18 %) are either in the ICUs or undergoing active weaning in a designated weaning unit. Of note, none of the ICCM-TT proceduralists acquired COVID-19 infection, all have been tested negative for antibodies. This may be due to the thorough pre-procedural planning, adherence to ICCM-TT protocols and vigilance in maintaining infection control guidelines. CONCLUSIONS: Developing a dedicated tracheostomy team and following standard of care in timing of tracheostomy for COVID-19 patients avoided unnecessary delay of patient’s care without risk of viral transmission to the staff. This facilitated patient’s ventilator weaning and discharges, which improved ICU throughput. CLINICAL IMPLICATIONS: Our results support creating a dedicated tracheostomy team and following standard of care without the need to delay a necessary procedure for COVID-19 pneumonia patients. Furthermore, this deemed safe when infection control protocols were strictly followed. DISCLOSURES: No relevant relationships by Adel Bassily-Marcus, source=Web Response No relevant relationships by Ella Illuzzi, source=Web Response No relevant relationships by Roopa Kohli-Seth, source=Web Response No relevant relationships by Evan Leibner, source=Web Response No relevant relationships by Ahmed Mohammed, source=Web Response