WITH COVID HOSPITALIZATIONS dropping nationally and on the west coast, Cedars-Sinai Medical Center has just put one of its most successful pandemic innovations on hold, hoping it’s never needed again.
That innovation is the covid line team, which the hospital first created last year to place lines in covid patients in its medical ICU during the spring surge. The hospital’s second covid surge—which swamped the hospital from December into February—has passed, at least for now, so ICU personnel can once again place central and arterial lines themselves.
Evan Zahn, MD, director of covid line team and a congenital heart disease expert, describes the mothballing of the line team program as a “hibernation.” That’s because he’s realistic to know that the team may be back. A highly transmissible and worrisome variant is now circulating in California, and the team has already been brought out of hibernation once before.
“Within five days, we had a volunteer team of close to 20 physicians up and running.”
~ Evan Zahn, MD
Cedars-Sinai Medical Center
The covid line team originally came together in February 2020 when elective procedures were shut down and covid cases started to rise. Dr. Zahn, director of the congenital heart program in the Smidt Heart Institute, usually spends his days putting lines in babies. But he was asked to pull together a group of procedural experts from across the medical center to place lines in the covid ICU and offload that crucial but very time-consuming work from ICU staff.
“Within five days, we had a volunteer team of close to 20 physicians up and running, providing 24/7 ICU service,” Dr. Zahn says, noting that the covid line team stayed active into the summer. By July, “things had quieted down, so we went into hibernation for the first time. But right on schedule, a couple of weeks after Thanksgiving, we started hearing rumblings from the ICU: ‘Is there any way you guys could come back?’ We were up and running by Dec. 21.”
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Dr. Zahn and his team colleagues wrote up their outcomes from the first three weeks of the program last spring in an article published this February in The Journal of Vascular Access. He spoke to Today’s Hospitalist about what it took to bring together a host of different subspecialists into one cohesive group.
Who made up your original team last spring? And when you came back in the fall, were the same members able to join again?
All electives were down last spring, so we pulled together a variety of subspecialists. I’m a pediatric interventional cardiologist, and we had a pediatric cardiac anesthesiologist, adult anesthesiologists and a pediatric intensivist, as well as members of the hospital’s procedure team.
When we were asked to come back, some of us—myself included—could accommodate that into our schedules. But others were too busy because the hospital was fully open again. We ended up with a somewhat smaller team in December, and we added several new members, including senior fellows. Instead of providing 24/7 service as we’d done previously, we were on call 12 hours a day, seven days a week.
We were actually busier this winter than in the spring and summer, consistently placing eight to 10 lines a day. One person was the first call as well, with several of us on backup. We were never in a situation where we couldn’t do a line when asked, although it might take more than one call.
The ICU staff really adapted to our schedule, holding off placing lines at night in patients who were stable. Typically, we’ve had a big rush in the morning and then some in the afternoon before we leave. The ICU staff could certainly do an emergent line at night themselves, but those were few and far between.
In your journal write-up, you write that “experts may not necessarily combine to make an expert team.” How easy was it to bring different subspecialists together into a high-functioning team?
We were all expert at invasive procedures, but we’d never done them while donning and doffing PPE. You don’t realize beforehand what the impact of that is on your dexterity and vision and breathing.
With covid, you also want to do these as fast as possible to minimize your exposure and allow the nurse helping you to get back to caring for patients. So in February 2020, colleagues and nurses designed a full simulation of a medical ICU room in our simulation center. We all did sessions there before we ever stepped foot in a room with an actual covid patient. The sessions were all videotaped so we could review them and do instructional videos.
The simulation included all the equipment that would be in the room, so we’d have that situational awareness. We also practiced doing all the sterile prep with our equipment—we go in with an ultrasound machine and a sterile tray—outside the room. It’s unusual to do sterile prep outside the room but necessary to minimize our exposure inside.
We also had phenomenal logistics, getting everyone on a schedule with all the coordination and communication that entails. Once we were placing actual lines, we did rounds with ICU members every morning to streamline workflow. We also had weekly team meetings—by Webex—to talk about quality improvement and necessary changes, and to give each other feedback.
While we standardized all our safety processes, we left what we individually use for lines and how we get access up to personal preference. But we also all put our egos aside. When we first got together, it was pre-vaccine, we didn’t know much about covid and the patients were really sick. And the disease was really scary.
What changes came out of your group discussions?
As soon as we started placing lines, we started seeing arterial thrombi, and all the lines were going bad. We didn’t know if we were using the wrong kind of line or doing something wrong.
This was before everybody realized that these patients were hypercoagulable. We might have not been smart enough to publish it right away, but we knew right away there was something different with these folks. So we started to heparinize all our lines.
We also ended up placing many dialysis catheters, and I’d never put one in before. It turns out it’s very similar to placing a central—but it’s different, and I had my colleagues teach me.
I ended up thinking the line team was a helpful and unique solution. We placed lines very rapidly and saved time for the ICU nurses. We had very few complications, and we had no infections from that work among our team members.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.