key: cord-289806-6ihptx6n
authors: Martinez, Rebecca; Bernstein, Kyra; Ring, Laurence; Ona, Samsiya; Baptiste, Caitlin; Syeda, Sbaa; Aziz, Aleha; Robinson, Kenya; Valderrama, Natali; Sheen, Jean-Ju; D’Alton, Mary; Goffman, Dena; Gyamfi-Bannerman, Cynthia; Moroz, Leslie; Landau, Ruth
title: Critical Obstetric Patients During the Coronavirus Disease 2019 Pandemic: Operationalizing an Obstetric Intensive Care Unit
date: 2020-10-07
journal: Anesth Analg
DOI: 10.1213/ane.0000000000005253
sha: 
doc_id: 289806
cord_uid: 6ihptx6n

Supplemental Digital Content is available in the text.

This archetype includes a large number of juniorlevel providers, each of whom are supervised by tiers of more senior-level physicians, who are in turn overseen by a board-certified critical care attending who guides the care of the greatest number of patients. The newly established operating room intensive care unit (ORICU) accepted its first SARS-CoV-2 case on March 23, 2020, with a peak occupancy of 78 patients. The pandemic brought near-complete cessation of nonurgent hospital activities with the rapid expansion of critical care services, with the notable exception of the labor and delivery unit (LDU), which continued to have a full complement of patients presenting for obstetric care.

The incidence of SARS-CoV-2 infection among pregnant women admitted to LDUs in NYC hospitals was 15.4%, with 4.7% of them critically ill. 7 There were scarce data about the clinical trajectory of pregnant women with SARS-CoV-2 infection, specifically regarding the proportion of women requiring mechanical ventilation in the setting of critical hypoxemia. In addition to SARS-CoV-2 maternal morbidity, usual indications for maternal critical care such as hemorrhagic shock, preeclampsia, cardiac disease, sepsis, and rare fetal indications continue to drive a steady demand for obstetric critical care services, 8 for which obstetric patients are usually transferred to a surgical or medical ICU. 9 It became obvious by mid-March 2020 that our institution's ICU capacity would rapidly be surpassed and that transferring critically ill obstetric patients per the usual model of care would become challenging, if not impossible. For this primary reason, we made the decision to provide intensive care to obstetric patients on the LDU. By the time the obstetric ICU (OBICU) was fully operational (end of March), the volume demand was mildly curtailed by some patients electing to leave NYC; however, interinstitutional transfers for maternal or fetal indications provided steady demands for care, with fluctuations occurring week by week.

In this article, we describe the steps undertaken in response to the pandemic to create a continuously fully staffed OBICU on our LDU, replicating some elements that were implemented in the ORICU, in anticipation of the inevitable medical and surgical intensive bed surge at our institution.

The guiding ethos was to provide high-quality care in the OBICU for critically ill peripartum women (defined as beyond 20 weeks of gestational age through 1 month postpartum) requiring ICU care during this pandemic, equal to the quality of care they would have received in the surgical or medical ICU. To achieve this primary goal, we followed crisis model management strategies to secure appropriate staffing, space, and supplies. 10 Secondary goals included (1) increasing critical care knowledge and competency among providers of all levels who do not care for critically ill patients regularly; (2) ensuring providers' safety by implementing standards for personal protection, and (3) maintaining optimal communication, adaptability, and collegiality in a constantly evolving environment.

The OBICU structure is based off the innovative pyramidal staffing model that was implemented for the patients in the novel ORICU. 6 The ORICU was staffed by redeployed nursing, anesthesia, and surgical staff, with 1 critical care attending overseeing multiple cores, but multiple reasons justified adapting this established model (Figure) . 6 First, our LDU is located in the New York Presbyterian-Morgan Stanley Children's Hospital, remote from all ICUs (medical, surgical, and ORICU); accounting for the significant distance between our LDU and all adult ICU locations was key.

Second, we expected the OBICU to be at a significantly smaller scale than the 78-bed ORICU. Instead of transforming operating rooms (ORs), we planned to retrofit the existing 6-bed capacity high-risk rooms located on the LDU into the OBICU. Common indications for admission to high risk would be preeclampsia, cardiac conditions, preterm labor, and peripartum hemorrhage. These 3 high-risk rooms are equipped with maternal and fetal monitoring capabilities and telemetry to accommodate patients who require invasive and intensive monitoring. However, they were not previously equipped with ventilators or equipment traditionally used in an ICU.

Third, and most importantly, we recognized that to provide optimal maternal and fetal care throughout the pregnancy continuum, including the antepartum and postpartum periods, critically ill patients would require different care models. Prolonged maternal hypoxemia associated with severe SARS-CoV-2 infection may result in fetal hypoxemia and ultimately acidemia. Thus, an antepartum OBICU patient requires multidisciplinary decision-making regarding fetal monitoring and optimal timing of delivery for both mother and fetus depending on the gestational age. While uterine decompression (ie, delivery) may improve maternal respiratory status particularly in the third trimester, potential benefits need to be balanced against the known operative risks if delivering by cesarean, gestational age of the fetus, and desires of the patient or health care proxy. Shared decision-making for postpartum patients remains important, but lack of fetal concerns in postpartum patients simplifies the physiologic considerations.

Bearing in mind these unique considerations, a shared obstetric/anesthesia responsibility model was deployed, adopted from the staffing structure of the ORICU. However, a key difference is that the critical care attendings (ICU oversight) are not ultimately responsible for patient care decisions and provide ad hoc consultations if deemed needed by the obstetric anesthesia attending.

As of March 21, 2020, 1 designated obstetric house staff (senior resident or fellow) is the "first call" team member, reporting directly to the OBICU attending, the dedicated obstetric anesthesia attending who is the attending of record ( Figure) . This new role for the Obstetric Anesthesia team was designed with this unique intent to manage critically ill peripartum patients. Physicians dual-certified in Obstetrics and Critical Care may also consider covering as an OBICU attending; 1 attending from our institution qualified. The OBICU attending is in close communication with the maternal-fetal medicine (MFM) attending, as well as ad hoc with a designated Critical Care attending if specific questions arise.

This new role for an OBICU attending necessitated reconfiguration of the staffing model to allow for a second in-house obstetric anesthesiologist 24 hours a day. This occurred on March 21, 2020, after 2 postpartum patients with an initially unknown SARS-CoV-2 infection required a short admission to the adult ICU (both were intubated). 11, 12 One attending remained dedicated to supervising labor epidurals and operative cases while the other oversaw the care of the OBICU patients. Collaboration between the 2 attendings remained critical during surges in clinical demands. Creation of the OBICU did not require expansion of the anesthesia resident or obstetric anesthesia fellow coverage beyond the continuous coverage by 2 trainees. Staffing remained consistent for days, nights, weekends, and holidays. The nursing staffing model of the OBICU continued with 1:1 or 1:2 nursing to patient ratio, with 3-4 nurses working every shift, caring for a maximum of 6 OBICU patients. This remained similar to coverage of patients before the implementation of the OBICU. LDU nurses with critical care obstetric (CCOB) training are assigned to care for patients in the OBICU. The CCOB nurse has at least 2 years of experience and has received both formal training (2 weeks classroom and 2 weeks bedside dedicated ICU learning time) and informal teaching from senior-level nurses in caring for patients with critical illness. Nursing leadership from the postanesthesia care unit (PACU) and pediatric ICU also committed to further education and support of the CCOB nurses.

The addition of vital ancillary health services was also necessary. Leadership from the departments of anesthesia technicians, central venous access, extracorporeal membrane oxygenation (ECMO), facilities maintenance, ICU triage (adult and pediatric), nursing, nutrition, occupational and physical therapy, pharmacy, phlebotomy, respiratory therapy and social work committed to providing 24/7 coverage for OBICU patients should needs arise. A comprehensive list of contact information prominently displayed preferred communication methods (Table 1) .

Team rounds are conducted twice daily with inclusion of the obstetric anesthesiologists, MFM obstetricians, and OBICU nurses. Consultants such as pharmacists and respiratory therapists participate, as well. This large team meets in the nursing station with each member wearing mask continuously (in accordance with hospital policy) and socially distancing as much as possible. The "first call" conducts the morning preevaluation of each patient, gathering relevant data and performing a physical examination, and presents each case at the nursing station for a review of patients' vitals and fetal heart tracing, if relevant. An organ systems-based plan is developed by the team and approved by the OBICU attending. The plan is communicated to the patient by the OBICU and MFM attendings who examine the patient after rounds to minimize staff exposure. Between patients, all providers conform to institutional protocols of infection prevention and control. Ancillary services are contacted as needed and present on rounds if available.

We created the OBICU in the existing high-risk unit, which is immediately adjacent to the obstetric ORs, www.anesthesia-analgesia.org

Operationalization of an Obstetric Intensive Care Unit During SARS-CoV-2 Pandemic knowing that its function would require adaptation of the existing infrastructure (Supplemental Digital Content, Figure 1A , B, http://links.lww. com/AA/D221).

An early step was to ensure that all appropriate invasive and noninvasive monitoring devices, including those for maternal hemodynamic and fetal heart rate tracings evaluation, were functional for patient care. A trial run proved that the rooms were large enough to accommodate the needs of 2 patients, including maternal and fetal monitoring systems (Philips Intellivue MP70 Monitor, Avante Health Solutions; Philips Avalon FM50, Philips USA), invasive ventilators (NellCor Puritan Bennett 840 Ventilator System), and multiple infusion pumps (Baxter Sigma Spectrum). Centralized monitoring screens in the nursing station allow for the nurses to oversee patients' status while not in the room. As ventilator settings and alarms are neither visible nor audible with the existing monitoring system, standard baby audio monitors were purchased for continual observation of the ventilators.

Multiple spatial adaptations were necessary to improve safety for patient and staff members. A high priority was the conversion of the 3 rooms to negative pressure airflow to minimize the aerosolization of viral particles into the hallway when the room door was opened. With a conversion from positive to negative pressure, the rooms then met Infection Prevention and Control criteria for airborne isolation and provided safer intubating conditions. Further, negative pressure rooms expanded our ability to safely provide more invasive ventilation modes such as continuous positive airway pressure and high-flow nasal cannula. Hospital engineers installed a vacuum in each room then cut a large hole in a window for the venting of the room air outward. This created a negative pressure space, so any aerosolized material would be directed outside.

Another priority included the creation of spaces for donning and doffing. Donning stations with necessary equipment in a locked cart were placed outside each room. Personal protective equipment (PPE) included hats, masks with shields, gloves, and gowns. Doffing stations were located inside each room with relocation of the trash can next to the door and placement of an alcohol-based hand sanitizer dispenser near the door for immediate use.

While reconfigured to provide longitudinal care for critically ill women, the high-risk beds converted to OBICU beds maintained their capability for women to labor and deliver vaginally. OBICU patients requiring cesarean delivery continued to be transferred to the obstetric ORs as per usual before the pandemic.

Two patient-safety-related principles guided our supply chain strategy: preservation and reliable access of supplies. Contamination of equipment and supplies (including medications) placed in the room of a patient with SARS-CoV-2 infection meant that preserving and streamlining supplies were important considerations.

The team collaborated to the design of 3 new carts deployed outside each room (Supplemental Digital Content, Figure 1B , C, Table 1 , http://links.lww.com/ AA/D221): (1) isolation cart, (2) basic nursing supply cart, (3) anesthesia cart, in addition to the institutional code cart.

Rapid and safe access to ICU drugs while avoiding wasting unused but possibly contaminated vials may be a significant challenge at a time when national drug shortages are an issue. Structural difficulties prevented the relocation of a drug-dispensing machine into the direct proximity of the OBICU. However, the pharmacists adapted the centrally located, existing drug-dispensing machine to include standard medications available in adult ICUs. This included addition and expansion of sedatives, antiarrhythmic agents, vasopressors, and inotropes. These machines are restocked by the pharmacy teams daily. Point of care testing was possible with an epoc Blood Analysis System (Siemens Healthineers) at the nursing station of the OBICU. Anesthesiology residents and OBICU attendings trained and certified in its use are available continuously to run samples. These results automatically uploaded to the medical record and immediately available for interpretation by the team.

The OBICU can admit up to 6 critically ill peripartum patients with the capacity to provide monitoring, invasive ventilation, and management of respiratory failure and vasodilatory shock. The decision regarding patient admission to the OBICU is ultimately at the discretion of the OBICU attending. A joint taskforce of obstetric anesthesiologists and MFM obstetricians developed guidelines for admission (Table 2) . Based on these criteria, the covering OBICU attending determines if the patient is stable for standard care, needs admission to the OBICU, or has critical care needs exceeding the capacity of the OBICU requiring transfer to a standard medical or surgical ICU. We planned to consider transfer of complex patients including, but not limited to, those requiring cooling after cardiac arrest, continuous renal replacement therapy, ECMO, or mechanical circulatory support.

Education in the OBICU has been an area of rapid development. Significant growth and learning on all

www.anesthesia-analgesia.org levels of provider (technicians, nursing, house staff, attendings, support staff) has been a recurring theme during all stages of the outbreak and opening of the OBICU. Systems-based rounding was a new organizational structure for most team members; however, an overview of the benefits of this system as well as modeling by the OBICU attending facilitated rapid adoption of this model. Interdisciplinary teaching of a wide range of topics from arterial lines to oxygen administration techniques has been important to ensure that patients receive a standard level of intensive care.

Daily online lectures by the Internal Medicine or Anesthesia departments review critical care topics that are both general in nature and specific to SARS-CoV-2 infection; these lectures while targeted at residents were available to all members of the OBICU team. A virtual toolbox homes a compilation of online resource, articles, and recordings of previous lectures. All staff have access to these resources. New infographics with visual prompts for staff have been designed by the anesthesia residents to improve knowledge and optimize care.

There were several challenges that should be perceived as stimulating and constant opportunities for improvement. First, we developed the OBICU out of necessity during a pandemic with significant limitations on time, material, and personnel resources. Delivering ICU-level care in a space that was not designed for critical care imposes spatial inefficiencies. The quality of nursing care for critically ill patients is well correlated with outcomes, 13 and the majority of the nurses working in the LDU were not initially trained in CCOB. These paradigms are not unique to nursing; operating outside ones' scope of practice results in the delivery of care that is not as seamless as within teams that consistently work together with critical care patients. Occasionally the covering pharmacist and respiratory therapist were not invited to rounds; this required communication outside of the team rounds to minimize care oversights. In another instance, the heparin downtitration in the setting of supratherapeutic activated partial thromboplastin time was delayed because the covering resident was unaware of the titration protocols. Inevitable gaps in theoretical and applied knowledge must be filled by the team leaders, who have differing levels of comfort in managing details pertinent to critically ill patients.

Nonetheless, help from across the institution facilitated the OBICU function. PACU and pediatric ICU nurses offered to provide assistance as needed. Critical care physicians were available constantly for in-person consultations. Most importantly, because a joint effort of multiple departments collaborated to design the OBICU environment, each person's contributions to patient care on rounds are valued. The success of the system depends on a collaborative, communicative team.

Despite obvious challenges of designing and implementing an OBICU, this is a scalable model for expanding care services. There are many advantages for critically ill pregnant women to receive care in a closed unit where obstetric anesthesiologists and obstetricians/MFM are accustomed to working together. A timely decision to proceed with delivery, via labor induction or cesarean delivery, can optimize maternal and fetal outcomes in critically ill obstetric patients. Facile administration of neuraxial anesthesia can be particularly valuable in these patients as a strategy to avoid general anesthesia and its inherent risks (to both patients and providers) during the SARS-CoV-2 outbreak.

While our OBICU is led by the obstetric anesthesia team, its success is predicated on multidisciplinary effort with collaboration across departments (anesthesia, obstetrics, nursing, management, and critical care) to provide optimal medical care during a time of crisis. Daily virtual meetings with various stakeholders facilitated communication and allowed for www.anesthesia-analgesia.org

Operationalization of an Obstetric Intensive Care Unit During SARS-CoV-2 Pandemic rapid response to logistical difficulties. Collegiality and a commitment to team learning are important as the unit evolves. Twice daily multidisciplinary rounds with attendings from obstetrics and anesthesia remain a critical element for patient safety and ensure optimal communication. Finally, a commitment to flexibility and professionalism in the face of new clinical and operational challenges allowed for peripartum patients to receive high-quality, safe care during a global pandemic. E

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