Telesimulation for COVID-19 Ventilator Management Training With Social-Distancing Restrictions During the Coronavirus Pandemic

Background. In early 2020, the novel coronavirus pandemic forced communities around the globe to shut down and isolate. Routine graduate medical education activities have also been suspended as resident and fellow physicians-in-training have been re-deployed to support critical patient care services.Innovation. We developed a two-part hybrid telesimulation model to teach COVID-19 ventilator management strategies while physically separating a group of learners and an instructor from one another. Learners consisted of non-ICU health care providers with limited experience in ventilator management being redeployed to manage ICU level COVID-19 infected patients. In the first week, the video tutorial has been viewed over 500 times and we have facilitated 14 telesimulation sessions, including 48 participants comprised of hospitalists, emergency medicine physicians and physician assistants, pediatric residents, nurses, and a nurse educator.Conclusion. We believe that the combination of a video tutorial followed by an interactive telesimulation was successful in providing timely education during a coronavirus pandemic. Furthermore, it reinforced the value and flexibility in which simulation education could continue conveniently for learners despite significant restrictions in place during the coronavirus pandemic. Research is needed to assess the efficacy of this hybrid intervention in preparing healthcare workers and to determine if the knowledge is successfully transferred to the clinical setting.

Incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema in COVID-19.

Objective: The coronavirus disease 2019 (COVID-19) pandemic reached New York City in March 2020, leading to a state of emergency that affected many lives. Patients who contracted the disease presented with different phenotypes. Multiple reports have described the findings of computed tomography scans of these patients, several with pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Our aim was to describe the incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema related to COVID-19 found on radiologic imaging. Methods: A retrospective chart review was conducted of all confirmed COVID-19 patients admitted between early March and mid-May to two hospitals in New York City. Patient demographics, radiological imaging, and clinical courses were documented. Results: Between early March and mid-May, a total of 1866 patients were diagnosed with COVID-19 in the two hospitals included in the study, of which 386 were intubated. The majority of these patients were men (1090, 58.4%). The distribution of comorbidities included the following: hypertension (1006, 53.9%), diabetes (544, 29.6%), and underlying lung disease (376, 20.6%). Among the 386 intubated patients, 65 developed study-specific complications, for an overall incidence of 16.8%; 36 developed a pneumothorax, 2 developed pneumomediastinum, 1 had subcutaneous emphysema, and 26 had a combination of both. The mean time of invasive ventilation was 14 days (0-46, interquartile range = 6-19, median 11). The average of highest positive end expiratory pressure within 72 h of study complication was 11 (5-24) cmH20. The average of the highest peak inspiratory pressure within 72 h of complication was 35.3 (17-52) cmH2O. In non-Intubated patients, 9/1480 had spontaneous pneumothorax, for an overall incidence of 0.61 %. Conclusion: Intubated patients with COVID-19 pneumonia are at high risk of pneumothorax, pneumomediastinum, and subcutaneous emphysema. These should be considered in differential diagnosis of shortness of breath or hypoxia in a patient with a new diagnosis of COVID-19 or worsening hemodynamics or respiratory failure in an intensive care unit setting.

Percutaneous and Open Tracheostomy in Patients With COVID-19: The Weill Cornell Experience in New York City.

OBJECTIVE: Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN: Review of prospectively collected data. METHODS: Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS: One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION: Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2849-E2856, 2021.

Percutaneous and Open Tracheostomy in Patients with COVID-19: Comparison and Outcomes of an Institutional Series in New York City.

OBJECTIVE: The aim of this study was to report the safety, efficacy, and early results of tracheostomy in patients with COVID-19 and determine whether differences exist between percutaneous and open methods. SUMMARY BACKGROUND DATA: Prolonged respiratory failure is common in symptomatic patients with COVID-19, the disease process caused by infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Tracheostomy, although posing potential risk to the operative team and other healthcare workers, may be beneficial for safe weaning of sedation and ventilator support. However, short- and long-term outcomes remain largely unknown. METHODS: A prospectively collected database of patients with COVID-19 undergoing tracheostomy at a major medical center in New York City between April 4 and April 30, 2020 was reviewed. The primary endpoint was need for continued mechanical ventilation. Secondary outcomes included complication rates, sedation weaning, and need for intensive care unit (ICU) level of care. Patient characteristics, perioperative conditions, and outcomes between percutaneous and open groups were analyzed. RESULTS: During the study period, 67 consecutive patients underwent tracheostomy, including 48 males and 19 females with a median age of 66 years [interquartile range (IQR) 52-72]. Two surgeons alternated techniques, with 35 tracheostomies performed percutaneously and 32 via an open approach. The median time from intubation to tracheostomy was 23 days (IQR 20-26). At a median follow-up of 26 days, 52 patients (78%) no longer required mechanical ventilation and 58 patients (87%) were off continuous sedation. Five patients (7.5%) died of systemic causes. There were 11 total complications (16%) in 10 patients, most of which involved minor bleeding. There were no significant differences in outcomes between percutaneous and open methods. CONCLUSIONS: Tracheostomy under apneic conditions by either percutaneous or open technique can be safely performed in patients with respiratory failure due to COVID-19. Tracheostomy facilitated weaning from continuous intravenous sedation and mechanical ventilation. Continued follow-up of these patients to ascertain long-term outcome data is ongoing.

Implementation of Simulation Training During the COVID-19 Pandemic: A New York Hospital Experience.

SUMMARY STATEMENT: Simulation played a critical role in our institution's response to the COVID-19 pandemic in New York City. With the rapid influx of critically ill patients, resource limitations, and presented safety concerns, simulation became a vital tool that provided solutions to the many challenges we faced. In this article, we describe how simulation training was deployed at our institution throughout the course of the pandemic, which included the period of our medical surge. Simulation helped refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers in unfamiliar roles. We also discuss the obstacles we encountered with implementing simulations during the pandemic, the measures we took to adapt to our limitations, and the simulation strategies and end products that were derived from these adaptations.