Folding a neuroscience center into streamlined COVID-19 response teams

Limit those entering our health care facilities

The neurology department joined the Montefiore Hospital System in redeploying staff to reduce the number of individuals entering the hospital and clinics to mitigate potential nosocomial spread of COVID-19.⁴ We consolidated all inpatient neuroscience services from all 3 hospitals to the Montefiore Medical Center (Moses campus), whereas the other 2 legacy hospitals maintained consultation (telemedicine and as-needed in-person) services. A list of departmental staff and house staff with high-risk conditions (hypertension, diabetes, immunosuppression, and/or age >65 years or an immunosuppressed cohabitant) was identified privately by self-report to designated senior leadership. High-risk staff were removed from the patient contact care and placed into a pool for remote clinical, administrative, and teaching services. One neurology resident was excluded, and another individual's schedule and roles were adjusted to accommodate for high-risk screening conditions.

To further reduce exposure, our hospital system excluded all visitors, with rare, prespecified, exceptions (such as non-COVID end-of-life care). All logistics and department meetings were converted to virtual meetings. Educational sessions became teleconference lectures and conferences. Clinical clerkships for students were canceled, and we initiated the design of a new neurology clinical clerkship adapted to the new environment starting July 1, 2020.

Our epilepsy monitoring unit was closed, and elective neurosurgeries were canceled on March 16. These changes reduced exposure of patients to the hospital as COVID-19 admissions began increasing. The reduction in elective admissions provided additional inpatient beds in the neuroscience unit to house the increasing volume of patients with stroke transferred from network and outside hospital sites.

The stroke service was the first division to reorganize, designating teams to cover the inpatient stroke service, hospital consult, and outpatient teams. The hospital consult team covered requests for transfer from outside hospitals, emergency department consults including orchestration of tPA and mechanical thrombectomy, and inpatient stroke follow-ups via electronic consult (E-consult). For emergency department (ED) and inpatient consults, the patient history was obtained by the neurology consult resident; chart review was performed by the resident and consult attending; and physical examinations were performed by either the primary team or a neurology resident, as needed. All outpatient stroke center visits were transitioned to telehealth.

Mirroring the stroke division, the size of all in-person clinical teams was reduced. Additionally, staff with high-risk medical conditions were excluded from direct patient care. Where possible, teams conducted rounds virtually, and met in person only when necessary for patient care. When feasible, attendings performed any bedside procedures to limit exposure of house staff and physician assistants and to conserve PPE. This system required the development of a robust E-consult neurology service. To facilitate E-consult, templates were developed for our electronic medical record. The E-consult team was staffed with experienced residents (postgraduate year 3-5) going to the bedside when necessary. Supervision and teaching was staffed remotely by at-risk faculty to shield them from patient-facing care. In rare situations, inpatient attendings were used as backup to answer more complex bedside questions.

Early hurdles included frequently rotating team members with increased handoffs, working longer shifts, and limited access to diagnostic testing (such as MRI, EEG, and nerve conduction studies) to reduce nosocomial transmission. Neurodiagnostic testing protocols where adapted to protect technicians and staff when medically necessary EEG⁵ and nerve conduction studies were requested. Increased attention to direct sign-out and formal communication with other divisions helped reduce the risk of multiple handoffs. To decrease the burden of increased hours, our hospital system and department supported staff with free parking, free meals, reimbursed travel, and partnerships with regional hotels.

We deployed telemedicine resources using phone or video conferencing at the preference of the individual/family to avoid unnecessary exposure while still providing robust outpatient neurology care.^2,4,6 This was facilitated on March 17 when the Centers for Medicare & Medicaid Services announced expanded Medicare coverage for telemedicine.^7,8 Our model was similar to the virtual neurology plan described by Grossman et al⁹ and included history, a modified virtual examination, coding, and billing. In addition, our stroke team colleagues developed a rapid adapted stroke assessment early in the response period.¹⁰ At this stage, we maintained outpatient neurology care by identifying patients for whom an in-person visit was essential. In addition, the outpatient case managers and social workers continued their roles through telephone or telemedicine services.

We defined essential patients as those with refractory conditions that could not be managed remotely and that potentially required admission to the hospital. We arranged video visits when possible, but some patients lacked internet access or were uncomfortable or unable to use the technology needed for video visits. Therefore, most encounters, especially early on, were conducted by telephone without video. These visits were received well, often with relief, by patients worried about the risk of exposure in a doctor's office. Many, particularly those with childcare responsibilities or limited mobility, preferred the convenience of in-person visits. On April 1, our hospital implemented an HIPAA-compliant video telehealth system, which made it easier for a rising proportion of patients to access video visits as this system has improved. As the number of patients with COVID in the New York area dropped, the small number of patients uncomfortable with telehealth services could schedule in-person visits.

Reducing essential personnel

The department identified nonfrontline health care workers who could transition to remote support, or those whose standard responsibilities were substantially reduced, and assigned them support roles for our teams. In our department, we defined nonfrontline staff as departmental administrative staff and outpatient clinic secretaries. Team members who were not supporting a telehealth service remotely were each given remote tasks to support house staff education programs and departmental administrative tasks.

Stroke cohorting

On March 19, we initiated network-wide stroke cohorting, with automatic transfer of all ED patients with stroke from our legacy hospitals to our inpatient stroke service. This increased efficiency and reduced wait time for beds at the other legacy hospitals.

Hospital redeployments

Simultaneous to stroke cohorting, our department underwent significant redeployment of neurology attendings, fellows, and residents to COVID-19 respiratory illness work, including ED screening tents (March 22), a COVID-19 respiratory illness Med-Surg ward (housed in the previous attending-only neurology ward) (March 29), and multiple COVID-19 ICUs (April 2).

The Montefiore Health System administration, on March 20, asked each department to provide a list of available staff for redeployment. Departments were assigned various deployment assignments throughout the hospital. Given the extensive experience of neurologists with critically ill patients, neurology was one of the few nonmedicine departments to be selected for deployment to COVID-19 ICU work in addition to staffing the COVID-19 tents and a medical COVID-19 ward.

Deployment staffing model

50% of neurology residents, fellows, and nonexempt faculty were needed for staffing a full Med-Surg COVID-19 unit and helping staff multiple COVID-ICUs. Junior residents (PGY1-3) were used for redeployment, and senior residents and fellows (PGY4-6) were used for barebones staffing of our consultation and inpatient units. Using this model, our consult services could have supervisory attendings working almost exclusively remotely, and in-person attending evaluations were the exception rather than the rule. However, limited house staff for our inpatient services increased the attending burden for high-volume services such as stroke.

Within the NSICU, outside rotators from a local emergency medicine residency stopped completely a few weeks into March. The critical care fellows normally on service throughout the week were often redeployed to other ICU support roles. Rotators from neuroscience specialties were also not available to the NSICU critical team during the emergency redeployments.

The hospital mobilized a majority of its beds for respiratory illnesses, whereas the neurology department joined a select group of services (psychiatry and oncology) in the system, proposed a staffing organization to maintain some inpatient specialty services, and provided a list of available clinical staff for redeployment. Although the stroke faculty possessed skills useful in an ICU, they were not redeployed but took over roles previously staffed by the general neurology faculty and medicine hospitalists, including management of a census of stroke patients with higher acuity than usual, with more transfers from outside hospitals and immediate transfer to the NSPCU after thrombectomy.

To support redeployed nonmedicine clinical staff, our critical care and internal medicine colleagues provided webinars and orientation sessions and an internal document with suggestions for COVID-19 management of respiratory distress, pneumonias, electrolytes disturbances, acid-base disorders, acute kidney injuries, and monitoring inflammatory markers for possible cytokine storm. This was complemented by on-site support via a rapid E-consult process with an on-call medicine hospitalist COVID-19 advisory team, including our nephrology, hematology, infectious disease, and critical care colleagues.

On March 25, the NSICU was closed to neuroscience ICU patients and reopened as an extension of medical ICU space. NSICU patients without COVID-19 were housed in the postanesthesia care unit, with increased pressure to bring these patients to the NSPCU, typically after 2 hours of recovery, per protocol.

Our ICUs were not formally converted to Medical COVID-19 critical care units; rather, the ICU case load required a major expansion of ICU bed capacity. The most critically ill patients received the ICU beds. During the peak of the crisis, this happened to be almost entirely patients with COVID-19; however, a small number of patients without COVID continued to be admitted to the ICUs as well. At the Montefiore Medical Center, our hospital and critical care leadership added ICU capacity by converting a former medicine ward, a pediatric ward, and a postacute care unit in ICU beds. In addition, an off-site ambulatory surgery center was converted to accommodate surge capacity of ICU and medicine beds. The administration also explored conversion of the operating rooms to ICU beds; however, that area was closed only after admitting 1 patient and a decline in cases.

Nursing and clinical support staff

For the most part, the nursing staff stayed with their units; some neuroscience nurses were called upon to help ICU nursing when additional staffing was needed. Some staff in the hospital nursing float pool also supported the ICU nursing as helpers. Many outpatient and ambulatory surgery center nurses were redeployed to inpatient areas based on their skill set. Some nursing staff who had been designed as higher risk were tasked as educators to train and orient newly arrived nursing graduates as helpers during the crisis.

Rapid discharge to rehabilitation

Case managers and social workers maintained their focus on transitioning patients out of the hospital with all rehabilitation and long-term care facilities receiving patients. On March 27, Burke Rehabilitation Center, an affiliated primary acute rehabilitation center for our health system, began accepting patients with COVID-19 and instituted a relaxed insurance approval process without rehabilitation medicine screening. This critically reduced the length of stay, which effectively increased unit capacity and improved flow through the neuroscience unit.

ED bypass protocol

On March 31, we launched an ED bypass protocol modeled on the pathway to mechanical thrombectomy, where patients with stroke with acute large vessel occlusions travel directly from CT to angiography suite to the NSICU without entering the ED. In the bypass protocol, all patients with stroke arriving directly to Moses traveled straight from CT to our stroke unit, where they received all laboratory testing and acute evaluation previously performed in the ED. Patients arriving from EDs of other hospitals also went directly to the stroke unit without passing through the Moses ED. For this model to be effective, single-room crash beds capable of accepting patients with unknown COVID status had to be available at all times. Two single-room negative pressure rooms were reserved for patients requiring aerosolizing procedures or oxygen via a high-flow nasal cannula.

Availability of disease-modifying care interventions

Thankfully, our health system's acquisition of additional emergency ventilator equipment allowed for sufficient airway support options in the areas covered by our neuroscience colleagues. System wide, we did encounter a shortage of high-flow nasal cannula equipment; however, any acute respiratory decompensation was managed in coordination with our critical care teams, and all patients who required ventilator support received care as indicated by their code status. There were no new ethical issues or change in the protocol for determination of code status.

As COVID-19 management evolved, the recommend treatment algorithms included placing a substantial portion of patients with COVID-19 on anticoagulation (mostly factor Xa inhibitors). The day after this recommendation was disseminated to hospital staff, there was a shortage for several hours as our pharmacies reassessed the volume of need. Within 12 hours, the supplies for factor Xa inhibitors were restored and future orders were adjusted accordingly. This experience resulted in hospital and department leadership, considering other support services that should be included in management planning.

In our stroke interventions, standards and protocols for mechanical thrombectomy did not change, and COVID status, which was often unknown when treatment began, did not affect eligibility. There was no rationing of disease-modifying stroke care including tPA and mechanical thrombectomy.