Preparing a neurology department for SARS-CoV-2 (COVID-19)

Inpatient neurology services

During the early phase of our preparations, nursing leaders on our neurology units provided training for donning and doffing of personal protective equipment (PPE), nasopharyngeal sampling technique, review of protocols for patients who are persons under investigation (PUIs), and screening of our patients for possible COVID-19 symptoms. Hospital-based guidelines are reviewed regularly. A checklist that the nurses completed is performed for all patients admitted to our units for possible COVID-19 symptoms. As community spread continued to rise, this checklist is now performed daily on all our inpatients. A COVID-19 binder was created on each unit to compile COVID-19–related documents including clinical guidelines, hospital protocols, and policies and our daily operations. A daily nursing huddle occurs to share information on COVID-19 and discuss PUI and COVID-19–positive cases on the unit. All trainees and inpatient neurology team members were trained in the same manner regarding proper PPE use, protocols for PUIs, and education around caring for patients with COVID-19 routinely.

Inpatient leadership and our chief resident developed a schedule to scale down our inpatient services to necessary staff including resident trainees (figure). Backup schedules and defined skills for redeployment (inpatient clinical, outpatient clinical, administrative, and language skills) were performed for trainees, neurohospitalists, and the neurocritical care team. Medical students and observers were removed from clinical services as was mandated by our hospital in early March. All teams practice social distancing when rounding and teaching is occurring in workrooms and not at the bedside. We minimized the number of team members entering patients' rooms to the attending for PUIs or those who were COVID-19 positive. We are bundling orders and adjusting routine care (i.e., laboratory draws, the frequency of neurologic checks, and timing of medication administration) to the minimum to provide adequate care while being conscientious of nursing exposure time in PUI and COVID+ rooms.

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Figure Personnel changes on neurology inpatient services during the COVID-19 pandemic

All elective admissions for nonurgent purposes were canceled in early March, and our epilepsy monitoring units (EMUs) were closed in both pediatrics and adult services. All urgent admissions and possible transfers were screened via phone for possible COVID-19 symptoms (including family members living in the same household) and accepted only if we could provide urgent management not available elsewhere. Rescreening for possible COVID-19 symptoms occurred when a patient arrived from an outside hospital or was directly admitted to our inpatient unit. If a patient was unable to answer questions regarding symptomology, which is the case in many of neurologic patients, we assumed that these patients may have COVID-19 infection during ongoing community spread and considered them a PUI in consultation with our infection prevention and control (IP&C) experts. All COVID-19–positive patients were centralized to designated hospital units and specialized COVID-19 teams as the pandemic in New York continues to rapidly evolve. Patients with primary neurologic conditions who are COVID-19 positive or PUIs remain on our neurology services. Thus, training of PPE donning and doffing and PUI protocols were essential for our inpatient team members.

Neurology consult services

On our neurology consult services, we transitioned to curbside consultations, reserving in-person consultations for urgent inpatient issues and ED consults (i.e., new brain hemorrhage, acute stroke consults, and ongoing seizures). All EEGs ordered by non-neurology teams for PUIs and COVID-19–positive patients were required to be approved by our neurology consult teams to avoid unnecessary studies in the context of limited PPE and to protect EEG technicians. We subsequently developed mechanisms to expand our inpatient teleneurology services to our EDs and inpatient services.

Acute stroke care protocol in the ED includes temperature check, oxygen saturation measurement, and COVID-19 symptom screening before performing the NIH Stroke Scale. If the patient cannot answer the screening questions, we assume the patient is COVID-19 positive requiring the use of PPE. The availability of PPE is an ongoing challenge in NY and many other regions of the country.

We changed our tissue plasminogen activator, thrombectomy, intracranial hemorrhage, and subarachnoid protocols across the hospital system enterprise to concentrate care, allowing nursing care to focus on the COVID-19 surge of patients in the ED. Stroke care coordination across NYC centers has been essential with frequent citywide meetings involving neurointerventional radiologists, neurocritical care directors, stroke team leaders, and neurosurgery.

Neurocritical care unit

Currently, approximately 20% of our inpatient COVID-19–positive patients require intensive care unit (ICU) support, and thus, a significant number of COVID-19–positive patients have been moved to the care in neurocritical care unit (NICU). Our ICU director frequently coordinates with hospital ICU directors to optimize the care of critically ill patients with COVID-19. There has been rapid development of protocols around the safe management of critically ill patients with COVID-19 (i.e., intubation and other aerosolizing procedures and cardiopulmonary resuscitation). In early March, our NICU director and NICU faculty provided routine education and preparation to staff and trainees around acute respiratory distress syndrome management, guidelines for noninvasive positive-pressure ventilation and high-flow nasal cannula oxygen for patients with suspected or confirmed COVID-19, and ongoing clinical trials on antimicrobial and immunomodulatory treatments. Neurocritical care fellows were now deployed to maximize the care for critically ill patients with COVID throughout our hospital system. Our critical care rounding teams were split to include a COVID-focused team led by our neurointensivists, and a non–COVID-19 team focused on the COVID-negative neurologic critically ill patients lead by our neurovascular team (figure). Teams have been restructured to include essential personnel, with some team members providing remote support (i.e., pharmacists).

All intubations are performed by anesthesia for PUIs and COVID-19–positive patients. Early transfer of patients out of our NICU was prioritized with an emphasis on early tracheostomies and percutaneous endoscopic gastrostomy tubes, as well as early shunts. Our role in the prognosis and assessment of brain death is essential as neurologists, and protocols are in place with regard to patients with COVID-19. Making an accurate and reliable prognostic decision will reduce ventilator usage and conserve PPE resources. Guidelines from the American Heart Association (AHA) on neurologically related prognoses in patients with COVID-19 after cardiac arrest are being developed. Some of the early steps we are taking include establishing a neurologic examination by 1 intensivist, focusing on brainstem reflexes 48–72 hours after being off sedation, relying on spot EEGs rather than continuous EEG in select cases, and obtaining neuroimaging and somatosensory evoked potentials if feasible.

As with neurology patients in the ED, there was an early recognition that our NICU patients will not be able to provide the history to screen in which we have stressed to our institution the necessity of considering testing for COVID-19 in those circumstances in consultation with IP&C.

Ambulatory neurology

In early March, ambulatory staff including call center personnel and in-person patient greeters were trained to screen all patients and those accompanying the patient for possible COVID-19 symptoms. Patients were contacted to schedule their visit on a telecommunication platform, and all patients were screened for symptoms. An ambulatory care protocol established by our hospital system was followed. Transition to teleneurology visits began for our outpatient practices in early March with the complete transition by mid-March for all new and established patients. Plans were immediately implemented to provide laptops and technical support to enable all outpatient practitioners to practice remotely. Webinars and guides for both patients and providers were distributed rapidly to enable as many visits as possible to continue uninterrupted. The university-wide ramp down in nonessential research activities has enabled us to increase the availability of telehealth sessions by providers who had previously dedicated significant time effort to research. Each division in our department created guidelines on which clinical scenarios warrant an urgent in-person visit. Any in-person visit must be approved by the division head and departmental leadership. Home EEG testing has been expanded. Botulinum toxin treatment for migraine has been continued, after the appropriate screening, to prevent relapse and avoid ED visits. Neurology infusion center patients are delayed when appropriate, transitioned to home infusions, or consolidated in the main hospital infusion center. Urgent postdischarge telemedicine appointment slots were established in all divisions to allow for expedited ED and inpatient discharge when appropriate.

All in-person visits in our resident clinic were also converted to telemedicine or, if patients do not have the technical capacity to participate in video visits, to a telephone visit. Residents performed telemedicine visits remotely and staff with an attending (also remote) by phone or by Zoom meeting. For the patients who needed to be seen urgently or who came in person for an appointment (if we cannot contact them), we established a rotating call system whereby 1 resident and 1 attending were available to come in within 30 minutes if needed.