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This podcast is supported by an unrestricted education grant by Medtronic.

Dr Pam Peeke:

Hello and welcome to the Society of Critical Care Medicine's iCritical Care podcast. I'm your host, Dr. Pam Peeke. Today, we're going to be talking about decision-making with regard to tracheostomy and the adaptation for COVID-19 patients. I'm joined by three doctors from the University of Pennsylvania Medical Center, Dr. Joshua Atkins, an anesthesiologist and Airway Safety Committee co-chair; Dr. Christopher Rassekh, an ENT surgeon and otolaryngologist, Airway Safety Committee co-chair; and Dr. Ara Chalian, an ENT surgeon, otolaryngologist and System Safety Officer. Now, I want to set a little bit of a context after we first hear from each one of the physicians with regard to any disclosures to report.

Dr Joshua Atkins: Pam, this is Dr. Atkins, I'm a consultant for the Medtronic Company. And I also have funded research from the Becton Dickinson Corporation that's unrelated to the topics we're discussing.

Dr Pam Peeke: Thank you, Dr. Rassekh.

Dr Christopher Rassekh: I'm also a consultant for Medtronic and I'm a co-investigator on a small grant for a biocontainment device, which has a patent pending, which was assigned to the University of Pennsylvania.

Dr Pam Peeke: And Dr. Chalian?

Dr Ara Chalian: Dr. Peeke, I am a consultant for Medtronic.

Dr Pam Peeke: Excellent. And thank you so much. So welcome to all three of you. You know, setting the context here, global healthcare is experiencing an unprecedented surge in the number of critically ill patients who require mechanical ventilation. This is a kind of a keen grasp of the obvious for all three of you. And this is really requiring relatively long periods of ventilation in those who survive. And that means many are considered for tracheostomy. And this is primarily to free patients from ventilatory support and maximize scarce resources and we all know what that's like.

So we really want to understand now the essential considerations for tracheostomy in the COVID-19 setting. I want to start with you, Dr. Atkins. Can you set the picture here in the context for how you begin to look at this decision-making process?

Dr Joshua Atkins: Thanks very much, Pam. And it's a privilege to be with you and this distinguished group and our audience from the society. As many of our colleagues in the audience know, I want to start by reemphasizing the complex clinical issues such as COVID-19 tracheostomy are best approached with an integrated interdisciplinary and coordinated approach. And really this can be accomplished at any hospital or health system, usually by adapting existing operational frameworks. And that's exactly what we did at Penn Medicine.

Central to this was the Airway Safety Committee, which is an interprofessional multidisciplinary group that we have that includes representation from every service involved in airway care, from the intensivists to nursing and respiratory therapy. And basically, this committee served as an integrator of information on airway-related clinical issues from all the sources. Using this committee as the central integrator of information allowed us to identify challenges quickly with the right expertise in a coordinated way that didn't leave out the perspectives of any of the mission-critical departments or clinicians.

So when the first COVID-19 trait came through, the procedural team could have devised a plan and just, you know, proceeded independently and did the trach safely and effectively. Instead because of this existing operational framework, that team came to the Airway Safety Committee and asked us to lead in formulating a plan that could be implemented for all COVID-19 patients requiring tracheostomy across the health system.

And these open channels of bidirectional communication really are the foundation of effectiveness. And this is how the Penn Medicine COVID-19 Tracheostomy Task Force was born. The task force fundamentally recognized that COVID-19 patients in trachs would involve substantial changes in workflow, consult process, procedure location, nursing, other roles, protocol changes, equipments, and this added elements of fear and anxiety.

Fundamentally, we started with the simplest question of what is it even safe to do a tracheotomy in a COVID-19 patient and this dovetailed with all those broader issues. So we brought that task force together and included representation, not just from airway safety people involved in COVID-19, but also from the health system leadership that was involved in coordinating all COVID-19 issues across the system. And our system, which consists of six hospitals, subsequently specifically deferred guidance on tracheostomy decision-making to this task force. And then my colleagues, Dr. Rassekh, will be able to describe a little bit more in detail the operational details of that task force.

Dr Pam Peeke: All right. So what you're doing is you're saying that it's possible, given this incredible challenge that every hospital now has, to be able to make decisions in a very organized fashion that, right now, many places are faced with the challenge of limited and restricted resources. So there's a way out of this. Dr. Chalian, what are your thoughts about these challenges?

Dr Ara Chalian: Well, Dr. Peeke, I too am appreciating the chance to be with you. And Dr. Atkins laid the framework for this. I sit in two camps, really. I'm a clinician in the Department of Otolaryngology and I'm a Hospital Patient Safety Officer, the chair of the Patient Safety Steering Committee and meet in huddles every day going over events that are reported in our event reporting system.

And what my role really was to help bring the resources and the engagement of our C leaders, whether it's our CMOs, CNO, CEO, and COO into the mix to really empower the group that really has the expertise. And using some of the principles of high reliability, this group realized this was the perfect storm. The acuity of the patients, the fear of the patients, the medical issues of aerosol-generating procedures and the staff's preoccupation with getting it right yet being safe and patient-centered, created a perfect storm.

What we did, and a lot of my role is as a facilitator is to use the framework we have to moderate and modulate, bring these teams together. And that's really what happened. I think a lot of our organizations, our peer organizations and organizations throughout the community have similar teams. And the key is to let those teams use the skills they have in everyday operations. They may have to ramp up the frequency. They may have to ramp up the stress management. But what we really wanted to share with our peers here in the Society of Critical Care Medicine, and those who are listening who may feel like they're not in the critical care domain, but somewhat worried about this, this is doable. And it really was taking our everyday assets and deploying them in a way that allowed them to excel.

What we did appreciate though is we spent a lot more time meeting. We spent a lot more time listening to each other with open minds and challenging the ideas in a 360 path approach, so that these assets went beyond open versus closed trach, ICU versus OR, OR nurse versus ICU nurse, general surgeon versus trauma surgeon versus otolaryngologist versus pulmonologists to a team that actually started to focus on the disease, the patient and the situations in a very synergistic way. It was very powerful what we saw. And I think it actually took some of the stress and fear away for both the patient and their families, as well as our teams at the front line.

Dr Pam Peeke: I’m curious when you're doing this, when you're going through this process, Dr. Chalian, what was your greatest challenge? You had so many moving parts here and you described it so articulately, but when you get down to it, what was the biggest hurdle for you?

Dr Ara Chalian: One of the biggest hurdles, I think, Dr. Peeke and my peers will address this as well is we thought we would come away with one fantastic approach and all the others would be second tier, what we learned is that there has to be some team and situational adaptation to that group's comfort and skills to optimize the minimization of aerosol, the optimization of protection.

So the answer wasn't really what's the right way to do it, it was how to bring your team together to get the right outcome. And I think that's a little different compared to the way you and I, as intensivist and surgeons, look at answers. We're pretty linear and this required us to be a little bit more emotionally intelligent and adaptive.

Dr Pam Peeke: I think that with the challenge like this, the grand majority of intensivists are facing a lot of fear factor and a lot of pushback on the part of the team. How did you deal with that, Dr. Rassekh?

Dr Christopher Rassekh: Well, Dr. Peeke, thank you for allowing me to participate in this, and I want to thank the entire organization. I also just want to say what a privilege it is to get to work with people like Dr. Atkins and Dr. Chalian every day. They're two of the finest people that I've ever met. And this entire process in spite of the significant stress that it caused to have to understand that we were trying to make life-saving decisions where healthcare personnel were potentially at risk wound up being one of the real highlights of my career as we work this out.

And as Dr. Atkins and Dr. Chalian pointed out, the framework that we started with was really important, that we were already a very multidisciplinary team within our hospital and that team had expanded to our other entity hospitals, both the three downtown hospitals, as well as the other three. And so there was a lot of stress.

And, interestingly, before this actually started, one of our chief residents who's now on our faculty approached me about developing some guidelines in the event that we were asked to do a tracheostomy for a COVID patient. And almost concurrently, one of our interventional pulmonologists, who is one of the representatives of our Airway Safety Committee approached myself and Dr. Atkins and a few other surgeons to discuss how we should proceed on essentially what I guess we might call patient zero.

And so we developed this task force that was made up of many representatives of our multidisciplinary Airway Safety Committee, but also other individuals that really Dr. Chalian and Dr. Atkins recommended that were sort of system-based leadership. And it allowed us to begin to develop a multidisciplinary approach to this, which we were able to then communicate to all of our respective departments.

And another interesting thing that really occurred with all the aspects of this management, but in this particular, all of us had contacts both in our peer institutions in the United States, as well as in Europe and Asia and Oceana. And so we began communicating with particularly people in China and Italy and Europe, because they had already had some experience with this. We did at the time believe that the consensus seemed to be that the prognosis of patients who were going to require tracheostomy was extremely poor.

So our initial approach to this was that taking significant risks with healthcare personnel was not warranted. And so our initial recommendation on timing was that we should wait 21 days. And so we then wrote an article that outlined that recommendation, as well as some of the other variables, such as the location, the type of trach, whether it be open versus percutaneous, the number of personnel in the room, the level of personal protective equipment. At the time, we felt that PAPRs should be used. And then the post-operative management of the patients as well.

Our recommendation initially, as Dr. Chalian alluded to, was for open tracheostomy at the bedside, and we relatively quickly had three downtown hospitals engaged in the process and we began to have them be done. And we met weekly to discuss the changes and the results as we went. Ultimately, two surgeons in two of our hospitals, not all of them, but two of them began to do percutaneous tracheostomy, and eventually three different methods for percutaneous tracheostomy were used. And ultimately, we brought two of the other three entities in our system.

And if you ask me what the greatest challenge was, I would say that that transition from the three downtown entities to the models that were less engaged in our actual academic practice was probably the most challenging because there was such a mix of system-based practice issues in those other hospitals, and I think we learned a lot from that. We also partnered with colleagues from peer institutions, such as the university of Michigan and Johns Hopkins and NYU and many international colleagues and became much more involved in the global tracheostomy collaborative and ultimately got involved in publishing world experience. And we changed our guidelines substantially as we developed experience.

Dr Pam Peeke: I think that this is fabulous because this is an example of what you have to do when you have, for all intent and purposes, a global pandemic. You have global resources and kudos to your team for reaching out and networking and collaboratively working together to be able to solve this issue. And I think to Dr. Chalian's point, there's no one answer. What you're doing is you're developing a process and a decision-making blueprint.

And just listening to you, I think that anybody could really appreciate how complex this is. This did not happen overnight. There was a lot of trial and error and there was a period of time where you figured out what was going to be the best outcome for your team, but most importantly for the patient, especially since you know that when COVID-19 is considered for trach, you're looking at a mortality rate that's through the ceiling. And this is a very tough situation all the way around.

And I think that I'm also hearing that the challenge here is really working your way and navigating through this entire process to a point where you get a win-win for both the patient, as well as the entire team. Do you see this kind of decision-making process, this more organized strategic process taking place now in other institutions, Dr. Atkins?

Dr Joshua Atkins: I think that the pandemic overall, particularly in the United States, really has catalyzed senior leadership at many health systems to recognize the importance of coordinated decision-making. And so I think we are hearing that there is more of a move to bring all the parties together to help in that coordinated decision-making.

And I think that part of what we've learned through this is that to some extent there has been a fear among independent practitioners or satellite hospitals that one policy is going to be implemented and it may disrupt what they believe to be best practices or their usual workflows. And I think as my colleagues have pointed out that's exactly the opposite of what happened here, even though we did have coordinated decision-making and dissemination of recommended practices. And that's because everyone had the opportunity to contribute in a bidirectional way.

Through these weekly tracheostomy task force meetings, we were able to immediately share adaptations to our protocol that other practitioners at satellite centers had devised. And those could be immediately brought to bear on our own protocols. And so everyone felt that they had a voice and there was coordination, but not top down direction.

Dr Pam Peeke: Very, very interesting. And so you're talking about best practices and the fact that the expectation was, well, existent best practices may conflict with and in a significant way with what you were actually discovering was going to have to be best practices, only to find out that indeed people were more open and welcoming to these kinds of suggestions and recommendations, which is fantastic.

Walk us through for a minute what actually takes place in the decision-making. Let's take patient zero. Give us an idea of what your wonderful blueprint looks like in action. Who wants to take that?

Dr Christopher Rassekh: When we were looking at patient zero, we were very concerned that the prognosis of patient zero was going to be very poor. In fact, the data we had at the time actually suggested that the prognosis of this entire group would very poor. We subsequently found out that that's not actually the case, not only in our experience, but with the experience of others.

And so, for example, just to talk about one of the major shifts, was the issue of the timing of tracheostomy. There's been some data that has suggested that in fact, while the virus may still be found in the nose of patients as long as three weeks, that it's likely that transmissibility is not very high at 10 to 14 days. And in fact, one of the things we realized was that some of our practitioners were not using PAPRs and we never had a practitioner who converted to COVID positive. So using an N95 mask and face shield appeared to be a sufficient technique as well.

In addition, we found that percutaneous tracheostomy, if done with certain modifications, appeared to be equally safe to the patient as well as the practitioner. So a lot of these things evolved as we went through the process. And as Dr. Atkins and Dr. Chaldean alluded to, these weekly discussions, really every single time we would meet, there would be something new. And another challenge we had was just communicating this to the system. Because of the need to communicate to the system, our recommendations in a timely fashion, we actually went through several rounds of drafts of the recommendations. And the current one has been there for several months now. But the initial one was changed a couple of times.

Dr Pam Peeke: Interesting. So we have a new variant of COVID-19 that has now appeared and I think they're just calling it the sort of the British variant, although now it's clearly in many countries. And it is now estimated that by March, this much more contagious variant of COVID 19 will really have become the predominant type of virus. Is this going to change anything for you in any of your SOP?

Dr Ara Chalian: Dr. Peeke, I'd like to jump in on this year. You're right, what a new viral variant does as well as a new surge does is create stress and anxiety as you alluded to, but it creates opportunity. And the opportunity that is probably the one that will be most underestimated is the one of refreshing everyone's skills.

Dr. Atkins and Dr. Tiffany Chao, one of our current faculty, they made an outstanding video on how to doff and don PPE. Now, we assume everybody's game on for this right now, but I would say one of the things that each organization needs to visit is refreshing everyone on those skills and making sure they're crisp because we naturally lapse into a little bit of our own best practices, and we have to be game on, high precision, high reliability for this key part of the PPE.

The second thing is as we go into a more virulent phase of the virus or the surge, we probably should simulate more. Take the team that knows what they're doing. Put them in the simulation lab, have them articulate and codify and immortalize what they do well, but also watch it like you do on a football film or whether it's American football or global football, and look at the game and the process and revisit it and help our teams become very familiar so they can do it with their eyes closed.

The last part is to consider ramping back up our tools that create connectivity with the team, which is bringing the experts back in on the meetings, have them realize. As a leader, I would say my goal is to have everybody think like a high reliability person. Assume we still have opportunity to improve. Assume we still could be getting parts of this wrong. Don't simplify it too much. Be sensitive to give to the key people on the frontline that are operationally intuitive, as well as observant on this. Help our team become resilient to create new solutions because we really want them to do something that we didn't do last time.

We're trying to keep operations as normal as we can to take care of as many healthy people, as many of "healthy people" that need standard services and still keep the organization treating, curing and advancing the patient who has COVID through the recovery spectrum so that they can transition out of the acute phase hospital.

So I think this creates a great opportunity. Of course, it creates the stress, but people like you and I, like you said, this is all about twisting it around to turn our natural survival instincts into positives instead of negatives.

Dr Pam Peeke: In the midst of difficulty lies opportunity. And never have we ever seen a more apropos quote than it is for this viral pandemic to say the least. Something else I'm really drawing from all of you is the fact that this is a moving target, that there is no sitting down and writing a nice SOP and then walking away, that we're going to have more variance, we're going to have more challenges with regard to this one particular virus. And so it's a matter of staying on your toes. And it sounds as though what you have in place at the University of Pennsylvania is a dynamic system. One that is ready to constantly hit refresh and re-educate and re-up, which I think is exquisitely important to be able to survive this as a hospital system clearly for our wonderful patients, but also to be able to keep the team absolutely on the cutting edge, bleeding edge of these extraordinary challenges.

You know, as we draw this to a close, what I'm going to ask each one of you to do is I'd like you to just think for a second, if there was a real nugget of knowledge and wisdom based upon your extensive experience that you'd like to share with your peers on this podcast, what would it be? I'll start with you, Dr. Chalian.

Dr Ara Chalian: My nugget would be that most of our teams have defined who they are. In this situation, we broadened our team and we asked our team to go back to basics and walk the walk on their process and to hear each other out, patient in the center, team surrounding them and create all the connections and define what they really needed to keep the team on the cutting edge, as you said, the sharp edge of getting this right. What it involved was a little bit more meetings, and a lot more listening, but it led us to that nimble, responsive, cutting edge approach that you've kind of articulated almost better than we have in terms of what it takes.

Dr Pam Peeke: Awesome. Dr. Rassekh?

Dr Christopher Rassekh: Well, thanks. And, you know, I want to reiterate what you said in a slightly different way, and that is adversity makes you stronger. I think it did make us stronger and we did learn a tremendous amount and I'd like to offer that some institutions, some hospitals are going to go through what we went through, but there's a stagger, both because of just the nature of COVID. It affected us pretty early and it's affecting other hospitals more profoundly now.

And in addition to the literature, which we think ourselves and some other places that have had the experience have provided, we believe that we can continue to help people. And so I guess my nugget would be don't hesitate to reach out and talk to us and talk to others who had this experience early on.

Yes, it's a moving target, but we've have settled on quite a few guidelines that have stabilized for many things now. And we now have a considerable amount of data and publications lag behind data. And so, we just want to welcome the opportunity to help any other hospitals that we can.

Dr Pam Peeke: Fantastic. And I'm smelling a collaborative undercurrent here, which really seems to be a huge message from both of you. And Dr. Atkins, what can you add to this?

Dr Joshua Atkins: I'd like to just highlight paper from the New England Journal Catalyst that my former chair and now the CMO of CMS, Lee Fleisher, and Wharton professor Sigal Barsade published during the peak of the pandemic. And it looked at anxiety and fear and its underpinnings in the COVID-19 pandemic.

And the key findings were that transparency, particularly about PPE, acknowledgement of the anxiety and fear that clinicians were experiencing, encouraging the importance of wellness mentally and physically, and especially opening transparency of communication up and down the leadership and having access to knowing the latest data, whether the PPE was available, having the confidence in the training in the PPE and how to use it and knowing that all the information across the organization about the COVID, what variants were there, what the prevalence was, how people were doing, transmitting that information precisely and frequently was very important to reducing state anxiety, which can be a big contributor to burnout and exhaustion.

Dr Pam Peeke: I think that all of your peers in critical care have gotten a fabulous understanding and a context within which they can understand this challenge of a tracheostomy and the adaptations necessary for COVID-19 patients. I think each of you have done an absolutely outstanding job of articulating the high points and to educate and further enlighten your peers. Congratulations to all three of you. You did a fabulous job. And, with that, this concludes another edition of the iCritical care podcast. For the iCritical Care podcast, I'm Dr. Pam Peeke.

This podcast is supported by an unrestricted education grant by Medtronic.