Process improvement for emergent ECMO cannulation of critically ill COVID-19 and MIS-C pediatric patients

Introduction: Children diagnosed with COVID-19 or Multisystem Inflammatory Syndrome in Children (MIS-C) can have rapid clinical deterioration and may require emergent hemodynamic and respiratory support with Extracorporeal Membrane Oxygenation (ECMO). Wolfson Children's Hospital (WCH) is the only free standing children's hospital in Northeast Florida. The 20 bed Pediatric Intensive Care Unit (PICU) averages 1100 admissions per year and is a level 1 trauma center. During the most recent wave of COVID, our hospital saw significantly increased numbers of children with COVID-19 and MIS-C requiring hospitalization and medical treatment in the PICU. The ECMO team at WCH was consulted for initiation of ECMO on several critically ill children with COVID-19 and MIS-C. Some children required extracorporeal cardiopulmonary resuscitation (ECPR). Many of these patients had significant obesity and other co-morbidities complicating patient management including emergent cannulation for ECMO. Cannulating a patient for ECMO during active CPR has poor outcomes that can be further impacted by obesity and an inability to generate adequate blood flow through smaller vessels in obese children. Therefore, our center sought to evaluate patients earlier for ECMO and attempt to avoid ECPR or emergent cannulation. A daily rounding checklist for COVID-19 and MIS-C patients was developed and implemented with a goal of preventing delayed care and enhancing efficient communication among all members of the healthcare team. Purpose: The ECMO team and physician leadership developed a daily rounding checklist to enhance communication with the interdisciplinary team for all COVID-19 and MIS-C patients admitted to the PICU. The checklist is completed by the ECMO Coordinator upon admission for children requiring respiratory and hemodynamic support with daily updates by the ECMO team coordinators, pediatric intensivist, and pediatric surgeon. The checklist ensures that each patient admitted to the PICU with COVID-19 or MIS-C has the following patient information, laboratory and imaging studies documented in the event the patient rapidly deteriorates and requires emergent cannulation for ECMO. Checklist information includes: patient weight, BMI, co-morbidities, cardiac echocardiogram to evaluate cardiac function, ultrasound of neck and femoral vessels to determine cannula size, head ultrasound (if applicable), patient's current condition (improving, unchanged, or deteriorating), type and cross, and candidacy for ECMO. The checklist allows all members of the healthcare team to have pertinent patient information readily available allowing expedited initiation of ECMO if needed. Implementation: The ECMO Coordinator consults with the attending pediatric intensivist and pediatric surgeon daily. Once the rounding checklist is completed, it is updated daily. If any items have not been completed, the ECMO coordinator recommends completion of missing testing or laboratory studies to the ICU team. Information gained from the ECMO Coordinator rounds is then added to the checklist and distributed to physician leadership, the PICU attending, ECMO medical directors, and the pediatric surgical team. If candidacy of a patient for ECMO is questionable, discussion occurs with the pediatric intensivist, pediatric surgeon, and ECMO medical directors to determine ECMO suitability. For high-risk patients, a primed circuit and catheters are available at the bedside with the ECMO team on standby. Outcomes: The implementation and utilization of this checklist has streamlined the process to determine suitability of children with COVID-19 and MIS-C that may require ECMO support at WCH. The process has enhanced patient care allowing a primed circuit, appropriate sized catheters, and discussion with the cardiovascular team in the event that thoracic cannulation may be required. This checklist is now being utilized for all patients that may require ECMO support allowing improved communication and collaboration between the pediatric intensivists, surgical group, and ECMO team.

North American Survey on the Effects of the COVID-19 Pandemic Shutdown on DBS Care

Objective: To evaluate the changes in multiple aspects of DBS care during onset of the COVID-19 shutdown. Background: During the initial COVID-19 shutdown, elective surgeries were cancelled in most U.S. and Canadian medical centers along with in-person office visits. On behalf of the Parkinson Study Group (PSG) this survey evaluated how deep brain stimulation (DBS) care at practices in North America was affected by the shutdown. Design/Methods: A RedCap ® survey supported by a UL1TR00142 grant was sent to all the members of the PSG Functional Neurosurgical Working Group. Survey responses were limited to one member per site and were collected from May 15-June 6, 2020. Results: Twenty three PSG sites (21 academic, 2 private practice) participated, including 19 (83%) sites in the USA and 4 (17%) in Canada. COVID-associated restrictions impacting DBS care were put in place lasting 4-16 weeks at various sites. A third of sites discontinued preoperative evaluations while the remaining offered limited preoperative evaluations. DBS practice changes affecting all aspects of care were reported, including preoperative assessments (96%), electrode placement (87%), new implantable pulse generator (IPG) placement (83%), IPG replacement (65%), initial DBS programming (74%), and routine DBS programming (91%). Though all sites reported institutional policy as a reason for practice change, 87% also reported patient-driven DBS surgery postponement due to COVID concerns. Conclusions: COVID-19 pandemic shutdowns resulted in restricted access to multiple phases of DBS care in almost all U.S. and Canadian sites in this large survey. While initial electrode and IPG implantation and initial programming can be deferred while continuing medical management, delays in IPG replacement (e.g., for a depleted battery or hardware failure) can result in potentially life-threatening consequences. This survey of real-world practice effects draws attention to the need for developing contingency plans for DBS care should pandemic shutdowns recur.

Assessment of deep brain stimulation candidacy during the COVID-19 pandemic: Lessons learned and future directions for neuropsychologists.

ObjectiveNeuropsychological assessment is integral to the pre-surgical deep brain stimulation (DBS) workup for patients with movement disorders. The COVID-19 pandemic quickly affected care access and shifted healthcare delivery, and neuropsychology has adapted successfully to provide tele-neuropsychological (teleNP) DBS evaluations during this time, thus permanently changing the landscape of neuropsychological practice. Method: In this paper, we discuss the lessons learned from the pandemic and we offer care management guidelines for teleNP and in-person evaluations of pre-DBS populations, with exploration of the feasibility of the different approaches for uninterrupted care access. Results: We summarize the strengths and weaknesses of these care models and we provide future directions for the state of clinical neuropsychological practice for DBS programs, with implications for broader patient populations. Conclusions: A better understanding of these dynamics will inform and educate the DBS team and community regarding the complexities of performing DBS neuropsychological evaluations during COVID-19 and beyond.

The global pandemic has permanently changed the state of practice for pre-DBS neuropsychological evaluations.

The evaluation and management of patients with movement disorders has evolved considerably due to the COVID-19 pandemic, including the assessment of candidates for deep brain stimulation (DBS) therapy. Members of the Neuropsychology Focus Group from the Parkinson Study Group Functional Neurosurgical Working Group met virtually to discuss current practices and solutions, build consensus, and to inform the DBS team and community regarding the complexities of performing DBS neuropsychological evaluations during COVID-19. It is our viewpoint that the practice of neuropsychology has adapted successfully to provide tele-neuropsychological pre-DBS evaluations during the global pandemic, thus permanently changing the landscape of neuropsychological services.