Elena Sandoval MD, FEBCTS.
The current COVID-19 pandemic has forced us to rapidly adapt to new ways of working, which may have been quite different from our usual practice.
Our hospital (Hospital Clínic Barcelona) is a bit different, as it has several independent intensive care units led by specific medical/surgical specialities. The pandemic has converted these “independent kingdoms” into COVID-ICUs and it has forced hospital leaders to create “new ICUs” for non-COVID patients. This conversion happened sequentially, moving from one COVID ICU patient on February 19th to 10 on March 10th and up to more than 100 on March 28th.
Regarding my department (Cardiovascular Surgery Department ICCV), how did the changes affect cardiac surgery? From March 16th, the number of available operating rooms for elective cases started to slow down until the complete cancellation of all elective cases, as ICU beds were occupied by COVID patients.
When it became our turn, the medical staff was separated in two groups; on one hand, fellows and residents (>2nd year) became the COVID group and started 12h-ICU shifts (previous COVID-ICUs experience taught us that longer shifts were unsustainable). These shifts also included colleagues from cardiology and cardiothoracic anaesthesia.
On the other hand, the most junior resident and the attendings remained as the “non-COVID” group and they were responsible for the in-house non-COVID patients and the emergent cases. We tried to keep the usual call schedule and the on-call team was responsible for the daily rounds.
All patients who needed urgent/emergent surgery were tested for Sars-Cov2 with a nasopharyngeal swab test in addition to a COVID profile lab test, to establish if they could be admitted in a non-COVID ICU or instead, they needed a COVID-ICU bed. From 8 eight who have undergone surgery in this period (2 endocarditis, 2 type A aortic dissections, one heart procurement, one coronary surgery, a pericardiectomy and a biventricular assist device insertion) 2 became positive and one was deceased due to COVID-19. All non-COVID patients were transferred to the newly adapted Coronary Care Unit.
All ECMO consultations were centred on the surgeon responsible for the mechanical circulatory support program. This surgeon evaluates all cases and if the case is accepted, this surgeon and one of the on call-surgeons organise and perform the implant, both in our centre (3) or in an outside hospital (2). If the ECMO is implanted in an outside facility, the recipient unit is the cardiovascular surgery ICU.
This same surgeon responsible for the implant is also in charge of the patients’ management in our ICU and works in direct collaboration with the treating physician of the ECMO patients admitted in other ICUs.
Currently, we have already started the “de-escalation process”. The Coronary Care Unit has become a non-COVID unit and both non-COVID cardiology and CV surgery patients have already been admitted.
We have planned to be able to perform one surgery a day, keeping the usual surgical teams. All patients will have been previously tested with a nasal swab and a COVID profile lab test. In cases there are doubts, a chest computed tomography will be performed to rule out infection.
We expect to recover the ICU as non-COVID and restore our usual surgical activity in the next two weeks.
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