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1.
Physician Leadership Journal ; 8(3):65-72, 2021.
Article in English | ProQuest Central | ID: covidwho-1813062

ABSTRACT

Engagement and morale are critical elements that contribute to effective functioning and goal attainment for individuals working together in an academic medical center. The COVID-19 pandemic was a significant and immediate threat to effective team functioning for physician academic departments. A department of surgery deeply engaged in the pandemic took multiple measures to maintain morale and engagement. To measure the effectiveness of these measures, the author compared survey data collected well before the pandemic with data collected from the same group during the pandemic. In 9 of the 19 compared questions, the responses were statistically significantly more positive or trended toward significantly better during the pandemic period survey when compared to the pre-pandemic survey. Maintaining morale and engagement through highly stressful circumstances requires intentional strategies and persistent execution.

2.
J Gastrointest Surg ; 26(1): 181-190, 2022 01.
Article in English | MEDLINE | ID: covidwho-1202825

ABSTRACT

BACKGROUND: Although acute gastrointestinal injury (AGI) and feeding intolerance (FI) are known independent determinants of worse outcomes and high mortality in intensive care unit (ICU) patients, the incidence of AGI and FI in critically ill COVID-19 patients and their prognostic importance have not been thoroughly studied. METHODS: We reviewed 218 intubated patients at Stony Brook University Hospital and stratified them into three groups based on AGI severity, according to data collected in the first 10 days of ICU course. We used chi-square test to compare categorical variables such as age and sex and two-sample t-test or Mann-Whitney U-tests for continuous variables, including important laboratory values. Cox proportional hazards regression models were utilized to determine whether AGI score was an independent predictor of survival, and multivariable analysis was performed to compare risk factors that were deemed significant in the univariable analysis. We performed Kaplan-Meier survival analysis based on the AGI score and the presence of FI. RESULTS: The overall incidence of AGI was 95% (45% AGI I/II, 50% AGI III/IV), and FI incidence was 63%. Patients with AGI III/IV were more likely to have prolonged mechanical ventilation (22 days vs 16 days, P-value <0.002) and higher mortality rate (58% vs 28%, P-value <0.001) compared to patients with AGI 0/I/II. This was confirmed with multivariable analysis which showed that AGI score III/IV was an independent predictor of higher mortality (AGI III/IV vs AGI 0/I/II hazard ratio (HR), 2.68; 95% confidence interval (CI), 1.69-4.25; P-value <0.0001). Kaplan-Meier survival analysis showed that both AGI III/IV and FI (P-value <0.001) were associated with worse outcomes. Patients with AGI III/IV had higher daily and mean D-dimer and CRP levels compared to AGI 0/I/II (P-value <0.0001). CONCLUSIONS: The prevalence of AGI and FI among critically ill COVID-19 patients was high. AGI grades III/IV were associated with higher risk for prolonged mechanical ventilation and mortality compared to AGI 0/I/II, while it also correlated with higher D-dimer and C-reactive protein (CRP) levels. FI was independently associated with higher mortality. The development of high-grade AGI and FI during the first days of ICU stay can serve as prognostic tools to predict outcomes in critically ill COVID-19 patients.


Subject(s)
COVID-19 , Gastrointestinal Diseases , Critical Illness , Humans , Infant, Newborn , Intensive Care Units , Prognosis , SARS-CoV-2
3.
Front Med (Lausanne) ; 8: 631335, 2021.
Article in English | MEDLINE | ID: covidwho-1106032

ABSTRACT

Objective: Examine the possible beneficial effects of early, D-dimer driven anticoagulation in preventing thrombotic complications and improving the overall outcomes of COVID-19 intubated patients. Methods: To address COVID-19 hypercoagulability, we developed a clinical protocol to escalate anticoagulation based on serum D-dimer levels. We retrospectively reviewed all our first 240 intubated patients with COVID-19. Of the 240, 195 were stratified into patients treated based on this protocol (ON-protocol, n = 91) and the control group, patients who received standard thromboprophylaxis (OFF-protocol, n = 104). All patients were admitted to the Stony Brook University Hospital intensive care units (ICUs) between February 7th, 2020 and May 17, 2020 and were otherwise treated in the same manner for all aspects of COVID-19 disease. Results: We found that the overall mortality was significantly lower ON-protocol compared to OFF-protocol (27.47 vs. 58.66%, P < 0.001). Average maximum D-dimer levels were significantly lower in the ON-protocol group (7,553 vs. 12,343 ng/mL), as was serum creatinine (2.2 vs. 2.8 mg/dL). Patients with poorly controlled D-dimer levels had higher rates of kidney dysfunction and mortality. Transfusion requirements and serious bleeding events were similar between groups. To address any possible between-group differences, we performed a propensity-matched analysis of 124 of the subjects (62 matched pairs, ON-protocol and OFF-protocol), which showed similar findings (31 vs. 57% overall mortality in the ON-protocol and OFF-protocol group, respectively). Conclusions: D-dimer-driven anticoagulation appears to be safe in patients with COVID-19 infection and is associated with improved survival. What This Paper Adds: It has been shown that hypercoagulability in patients with severe COVID-19 infection leads to thromboembolic complications and organ dysfunction. Anticoagulation has been variably administered to these patients, but it is unknown whether routine or escalated thromboprophylaxis provides a survival benefit. Our data shows that escalated D-dimer driven anticoagulation is associated with improved organ function and overall survival in intubated COVID-19 ICU patients at our institution. Importantly, we found that timely escalation of this anticoagulation is critical in preventing organ dysfunction and mortality in patients with severe COVID-19 infection.

4.
Ann Surg ; 274(1): 50-56, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1101932

ABSTRACT

OBJECTIVE: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. BACKGROUND: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. METHODS: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. RESULTS: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. CONCLUSIONS: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.


Subject(s)
COVID-19/prevention & control , Elective Surgical Procedures , Endoscopy , Infection Control/organization & administration , COVID-19/epidemiology , COVID-19/transmission , Consensus , Delphi Technique , Humans , Internationality , Intersectoral Collaboration , Triage
5.
Ann Biomed Eng ; 49(3): 959-963, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-1064528

ABSTRACT

Since the first appearance of the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) earlier this year, clinicians and researchers alike have been faced with dynamic, daily challenges of recognizing, understanding, and treating the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2. Those who are moderately to severely ill with COVID-19 are likely to develop acute hypoxemic respiratory failure and require administration of supplemental oxygen. Assessing the need to initiate or titrate oxygen therapy is largely dependent on evaluating the patient's existing blood oxygenation status, either by direct arterial blood sampling or by transcutaneous arterial oxygen saturation monitoring, also referred to as pulse oximetry. While the sampling of arterial blood for measurement of dissolved gases provides a direct measurement, it is technically challenging to obtain, is painful to the patient, and can be time and resource intensive. Pulse oximetry allows for non-invasive, real-time, continuous monitoring of the percent of hemoglobin molecules that are saturated with oxygen, and usually closely predicts the arterial oxygen content. As such, it was particularly concerning when patients with severe COVID-19 requiring endotracheal intubation and mechanical ventilation within one of our intensive care units were observed to have significant discordance between their predicted arterial oxygen content via pulse oximetry and their actual measured oxygen content. We offer these preliminary observations along with our speculative causes as a timely, urgent clinical need. In the setting of a COVID-19 intensive care unit, entering a patient room to obtain a fresh arterial blood gas sample not only takes exponentially longer to do given the time required for donning and doffing of personal protective equipment (PPE), it involves the consumption of already sparce PPE, and it increases the risk of viral exposure to the nurse, physician, or respiratory therapist entering the room to obtain the sample. As such, technology similar to pulse oximetry which can be applied to a patients finger, and then continuously monitored from outside the room is essential in preventing a particularly dangerous situation of unrealized hypoxia in this critically-ill patient population. Additionally, it would appear that conventional two-wavelength pulse oximetry may not accurately predict the arterial oxygen content of blood in these patients. This discordance of oxygenation measurements poses a critical concern in the evaluation and management of the acute hypoxemic respiratory failure seen in patients with COVID-19.


Subject(s)
Blood Gas Analysis/methods , COVID-19/blood , COVID-19/therapy , Oxygen/blood , Respiration, Artificial , Humans , Intubation, Intratracheal , Oximetry
6.
Ann Surg ; 272(2): e63-e65, 2020 08.
Article in English | MEDLINE | ID: covidwho-706917

ABSTRACT

BACKGROUND: A novel coronavirus (COVID-19) erupted in the latter part of 2019. The virus, SARS-CoV-2 can cause a range of symptoms ranging from mild through fulminant respiratory failure. Approximately 25% of hospitalized patients require admission to the intensive care unit, with the majority of those requiring mechanical ventilation. High density consolidations in the bronchial tree and in the pulmonary parenchyma have been described in the advanced phase of the disease. We noted a subset of patients who had a sudden, significant increase in peak airway, plateau and peak inspiratory pressures. Partial or complete ETT occlusion was noted to be the culprit in the majority of these patients. METHODS: With institutional IRB approval, we examined a subset of our mechanically ventilated COVID-19 patients. All of the patients were admitted to one of our COVID-19 ICUs. Each was staffed by a board certified intensivist. During multidisciplinary rounds, all arterial blood gas (ABG) results, ventilator settings and ventilator measurements are discussed and addressed. ARDSNet Protocols are employed. In patients with confirmed acute occlusion of the endotracheal tube (ETT), acute elevation in peak airway and peak inspiratory pressures are noted in conjunction with desaturation. Data was collected retrospectively and demographics, ventilatory settings and ABG results were recorded. RESULTS: Our team has observed impeded ventilation in intubated patients who are several days into the critical course. Pathologic evaluation of the removed endotracheal tube contents from one of our patients demonstrated a specimen consistent with sloughed tracheobronchial tissues and inflammatory cells in a background of dense mucin. Of 110 patients admitted to our adult COVID-19 ICUs, 28 patients required urgent exchange of their ETT. CONCLUSION: Caregivers need to be aware of this pathological finding, recognize, and to treat this aspect of the COVID-19 critical illness course, which is becoming more prevalent.


Subject(s)
Bronchi/injuries , Coronavirus Infections/therapy , Intubation, Intratracheal/adverse effects , Pneumonia, Viral/therapy , Respiration, Artificial/adverse effects , Trachea/injuries , Adult , Betacoronavirus , COVID-19 , Female , Humans , Intensive Care Units , Male , Pandemics , SARS-CoV-2
7.
Surg Endosc ; 35(7): 3430-3436, 2021 07.
Article in English | MEDLINE | ID: covidwho-647075

ABSTRACT

BACKGROUND: Surgeons are trained as "internists that also operate," bringing an important skillset to patient management during the current COVID-19 pandemic. A review was performed to illustrate the response of surgical staff during the pandemic with regard to patient care and residency training. METHODS: The evaluation and assessment of the changes enacted at Stony Brook Medicine's Department of Surgery is illustrated through the unique perspective of surgical residents. No IRB approval or written consent was obtained nor it was necessary for the purposes of this paper. RESULTS: Hospital policy was enacted to hinder transmission of COVID-19 and included limited gatherings of people, restricted travel, quarantined symptomatic staff, and careful surveillance for disease incidence. Surgical residency transformed as residents were diverted from traditional surgical services to staff new COVID-19 ICUs. Education transitioned to an online-based platform for lectures and reviews. New skills sets were acquired such as PICC line placement and complex ventilator management. CONCLUSIONS: The viral surge impacted surgical training while also providing unique lessons regarding preparedness and strategic planning for future pandemic and disaster management.


Subject(s)
COVID-19 , Infection Control/methods , Internship and Residency , Surgeons/education , COVID-19/epidemiology , Critical Care , Hospitals , Humans , Infection Control/organization & administration , Quarantine , Travel
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