Mayo Clinic experts discuss practical and ethical questions in critical care and ICU capacity management, with a focus on the COVID-19 pandemic.
Moderator: Erin S. DeMartino, M.D. , consultant, Pulmonary and Critical Care Medicine; assistant professor of medicine
Featured Expert: Daniel R. Brown, M.D., Ph.D. , chair, Division of Critical Care Anesthesiology; professor of anesthesiology
Featured Expert: Alice Gallo De Moraes, M.D. , consultant, Pulmonary and Critical Care Medicine; assistant professor of medicine
Featured Expert: Richard A. Oeckler, M.D., Ph.D. , consultant, Pulmonary and Critical Care Medicine; assistant professor of medicine and physiology
Featured Expert: Lindsey M. Lehman, M.P.H., M.H.A., operations administrator, Division of Critical Care Anesthesiology; assistant professor of health care administration
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The views and perspectives shared in these resources are presented based on information available at the time of recording.
welcome everyone and thank you for joining. I'm Teresa Malin, a senior education specialist, and on behalf of the Mayo Clinic School of Continuous Professional Development, I'd like to welcome you to the Mayo Clinic Covid 19 webinar series. Today's Webinar is on managing ICU capacity and ethics and health in crisis care. Today's webinar has been accredited for one m a credit. There are no relevant financial disclosures before we get started. We like to cover a few points, and the first is how you can claim credit for this webinar. If you'd like to claim credit after the Webinar, please visit ce dot mail dot e d u slash covid 0217 You'll need to log into the site. If this is your first time visiting, you'll need to create an account. After you've done this and logged in, you'll see an access code box like here in the middle of the screen. You want to type in today's code, and this is case sensitive. So in all caps, you want to type covid 0217 This will allow you to access the course. You'll complete a short evaluation and then you'll be able to download or save your certificate. This link and the code will be dropped into the chat box throughout today's WEBINAR. The second item I'd like to cover is how will facilitate questions so you'll see here at the bottom of the screen that there's a chat and a Q and A function. If you have any questions during the webinar for today's panel, it's important that you drop them into the Q and A channel rather than the chat box. This will ensure that the panel gets to see your questions. There's also a helpful up vote button, so be sure to use that vote button on the questions that you'd like to see answered. If you are experiencing any technical issues during the WEBINAR, please use the chat feature to share those so our support team can assist you. Today's learning objectives Upon completion of the webinar, learners should be able to identify innovative solutions to meet the needs of critically ill patients during the covid 19 pandemic. Also, they should be able to discuss the importance of information sharing, load leveling and coordinating scarce resource allocation across the region during a public health emergency, and lastly we should be able to describe practice redesign principles to extend critical care expertise into new settings. Leading today's discussion is our panel moderator, Dr Aaron De Martino. She's a consultant and pulmonary and critical care medicine here at Mayo Clinic and an assistant professor of medicine. With that, I'd like to turn things over to Dr Di Martino. Thank you, Teresa. It's a pleasure to be here and thank you all for joining us on this morning's discussion. I'd like to introduce you to the rest of our Panelists. Next slide first is Dr Daniel Brown, who is a professor of anesthesiology here at Mayo Clinic, Rochester and is the chair of critical care anesthesiology and, in fact, leaves the entire critical care practice across different disciplines and across all of the male clinic sites. Next time, we also have Doctor Alice de Gallo Damaris, who is one of my colleagues in pulmonary and critical care medicine. She is an assistant professor of medicine, and also importantly chairs are medical emergency response subcommittee. That's the committee that oversees activations of resuscitation is codes or other rapid response around the hospital, and so has a good lens, not only on what happens within the I C u. But also outside of the walls of the I C u Next. And finally, we have a vitally important member of our team. Our operations manager, Who is Lindsay Lehman? Ms. Lehman holds a masters of public health and masters of health administration, and also an assistant professor rank at Mayo Clinic. Uh, and she has been vitally important in, um, standing up our response and, um, helping our clinicians adapt to ever changing care, context and challenges in terms of care delivery so that we can continue to meet the needs of all of our patients next time. So before we jump into questions, I thought it would be useful to just spend a moment, um, covering some nomenclature. So we're all starting out on even footing in terms of, um, kind of agreed upon nomenclature for what even were talking about this morning, which is essentially care across what's known as the surge continuum. This is an expression that had been coined in the emergency management literature. And, um, there have been flurries of scholarly activity to help better define, um, what the surge continuum is and what the different phases along that continuum are, um, the last flurry of activity was around the H one n one pandemic, and obviously in 2020. There's been renewed interest in trying to define stages in the surge continuum and refine our as a medical as a medical community and even more broadly as a public health community, refine our response to strains on our system next life. So there are three stages within the search continuum, and those are conventional contingency and crisis under content. Conventional, uh, conditions, which would really be where we were in early early 2020 is a January of 2020. Um, we have to acknowledge that things were not equal. Even then. We weren't starting out with a level playing field. There were existing inequities in terms of access to healthcare and resources that we had relatively well resourced hospitals that could meet the demands of all critically ill patients who are presenting and other hospitals who, in their day to day practice, were struggling to find ICU beds for all the patients who are critically ill. Can you in balance, please? But by spring of 2020 we found ourselves in a situation where we were preparing for and in some regions of the country well, in the midst of a huge surge in patients where we were seeing maybe 100% on top of our normal capacity of ICU patients, 100% of additional patients, two times the number of patients were used to seeing and trying to find ways to adapt our practice so that we could continue to meet the needs of those patients became a major focus, while at the same time, particularly in ethics communities and, um, of which I am a part. I'm a clinical medical ethicists as well as practicing and our medical ICU. In the ethics communities. We were spending a lot of time thinking about crisis standards of care next time. And that's really, um, when we no longer have an expectation that we can meet the needs of all patients who are presenting critically ill and who need acute care hospitalization. And so while there have been moments in time in this pandemic where systems have been strained to the point that they have, um described their own operating conditions as crisis standards of care, most of what we've seen in 2020 and early 2021 has been an effort to forestall ever having to enter a crisis standard of care where there is no longer an expectation that we can meet all the needs of each critically ill patient coming into the hospital. And what that means is that we have had to find ways to adapt or practice to potentially practice in settings where we hadn't traditionally provided patient care or redeployed, um, teams from other aspects of the practice or other parts of the hospital to participate in the care of acutely ill patients. And some of those adaptations are really going to be the focus of today's discussion. So with that, I think will turn to some questions again. I want to encourage the participants in the webinar to please submit questions to us so that we can address the things that are at the top of your mind. But by way of introduction, I think we'll start with a question that our panel had come up with to share with all of you. So in this question is for Miss Lehman and for Dr Brown. Could you discuss how the staffing model at Mayo Clinic changed during various phases in the surge in patient volume. Maybe I'll start out Lindsay, if that's okay. Um, yeah. I mean, we did what I'm sure. Others on this phone call did in terms of identifying the available resources that we had, who could provide this type of care, who could perhaps backfill others to allow them to provide this care. And then, you know, So that's the personnel. Then you've got the space issues. We re evaluated all of our locations that we could provide care. And then, you know, the whole supply issue as well. And what I can just say is that you know, we shut our You know, we have a bit of unique practice here and that we have a large volume procedural practice that we wound down over a matter of roughly two days. And so several 100 procedures, 3, 300 procedures a day, depending on how you count them, went down to, in essence, a handful or two cases. So we had a tremendous amount of resources available at our discretion. On this campus alone, we've got about 160 beds, so we were able to absorb a lot of patients if needed, and we went beyond our traditional issue beds, which I'm sure others did as well. We went through the exercise of and actually, indeed moved critically ill patients down to one of our recovery rooms, for example, one of the aspects of our practice. That is not that it's unique, but just people need to be aware of is that with rare exception, most of the people at a physician level don't just practice critical care. They have other aspects of care, be it surgery, be it pulmonary medicine and clinic procedures, etcetera, anesthesiologists in the operating room. And so we were able to mobilise an awful lot of resources to that and where we had more difficulty. Or, you know, the nursing staff, for example, or a finite resource. Respiratory therapists. When we create these new locations, how do we get a pharmacist? How do we bring the whole team with us? And that's a considerable amount of effort to coordinate all that ensure that you have all the components that you need available what it allowed us, what it showed us was that the limitations that we had of our standard triage patterns and so those were revisited again and updated, I guess, for lack of a better word. And really, the situation we're in now I don't think is unique. Either we have a We have patients that are ill that are coming here that need care. We still have a population of covid patients as well. And so how do we coexist with these additional stressors on our system? And how do we prioritize, if you will, the care that's being delivered? And thankfully, right now, we don't have to do this prioritization. But you know, it's a constant issue of capacity and resource availability and meeting the needs of the patient. And so it's an ongoing issue and something that I suspect we're not done with, and we're going to have to continue. So in summary, I would say that we prepared for a for an onslaught of patients. Thankfully, that did not comment. At this point, those efforts are still being used as we continue to best manage our patient population internally. Lindsay, What did I what else warrants emphasis? I think you had all the high points. You know, staffing to workload is always the goal, right, But it was increasingly difficult to continually reassess what that meant throughout 2020. And now, as you said, we don't have the benefit of a decreased surgical practice. Therefore, a lot of additional resources available, so it will be a balance going forward. Um, but one of our long term takeaways, I think what you hit on is really our ability to have resources identified and agree upon the thresholds at which they have to be brought to bear. And then, just as importantly, how to stand up and stand down as that census right or patient Volume fluctuates. So I I do think that we will apply a lot of those lessons learned and are applying them. Um, but, you know, based on a specific number of additional patients, you know, we got to a point where we needed to bring those additional resources online. And as you said, those are often finite resources, so it can't be forgotten that we were tapping into the same group over and over. Um, and I think that's one of the questions that remains, is how who can do what responsibilities and how can we think a little differently about who can do that going forward thank you. Um, we have some questions coming in through the Q and A. I'll start with one, and maybe I'll direct it to Dr Gallo. I'm sure you will be sharing how you dealt with the ethical issues and informing patients and family regarding the severity of disease and chances of recovery. And this kind of overlaps with something that we had hoped to cover during today's WEBINAR was not just specifically the communication style, but what we've noticed, um, in having at different times in the pandemic no family members present in the ICU. Or maybe only one family member who is, you know, burden with having to communicate what they are bearing witness to at the bedside and how that's impacted decisions for patients and things like that. So I'm going to try to answer maybe in two parts. So how we dealt with the ethical dilemmas and and how to communicate with family, um, family members, uh, at the beginning of the pandemic when we absolutely said no visitors because again we were all trying to understand what was happening. Um, again, Just a reminder for all of our listeners. Um Covid, 19, is 12 months old is 14 months old. So again, we're still learning a lot of things even a year later. But at the beginning, when when we decided that no visitors were going to be allowed, our medical ICU director actually had a doctor. Oakland had a very good, uh, response to that, and he put ipads and wires and all of the all of the I C. U room so we could video chat with family members and update them at the bedside. I feel like that was very helpful, at least for me, in communication with family members. And the second part of your question, Dr DiMartino was, was how we dealt with, like, no visitors. Then one visitor again. Personally, I think having at least one visitor, um, is better for us. Uh, clinicians, and also better for patients, I believe when we allow the visitor back, um, delirium. I I don't have numbers to share, but delirium decreased. I feel like patients participated more even in physical therapy. Um, and again, this is my personal observation. I don't have numbers to back myself off on this one, but just watching a bedside and I cannot even begin to imagine how difficult it is to be the single family member of bedside having to share all of those, um, all of those, um, updates. And again, a lot of times we had to say, this is it. There's nothing else we can do here. Um, I can't begin to imagine how difficult that was for patients or family members. Um, but again, with the with the ipads and with the tablets, I'm sorry. And with with being able to call more family members from the room, um, I think was very helpful. And And maybe I can redirect the question to you because you know more about the ethics of everything. So maybe you could share your perspective to doctor the Latino. Yeah, I think that one thing that I would have I would add to what you've just said our amplify and what you've just said is how it impacted decision making. You know, I felt that as we particularly in the period of time, um, really, in the early in the pandemic, when we didn't have a good infrastructure and regular communications via videoconference with family, we were receiving far more questions from families say, over the telephone, asking if a patient who was paralyzed and prone would be ready to go back to work tomorrow. You know, like the types of, um, disconnect that we were seeing from what we were observing at the bedside and what patients families were understanding. Even in the midst of trying so hard to paint a picture for them and explain, I think a picture is worth 1000 words. And so while it's been heartbreaking not to have rooms full of family members for infection control reasons, that was literally not possible and remains not wise. And so, um, one way that we've been able to bridge some of that communication divide has been, um, through this access to, um to iPads and I would or tablets. And I would actually emphasize also what you said about when we have had, um, changes and relaxations and our visitor policy to the point that we have been able from a pandemic standpoint, to have family members present in the I C. U. With patients that it does seem like their course of delirium is shortened and it's less severe. Um, all of these things that we know our best practices from pre covid. Um, we're really witnessing in a totally new way now when we're having to, um, to isolate patients from their families. Um, and I think that that leads into some questions that I see populating in the Q and A and also something that we had hoped to discuss anyway was around, um the what we've done with visitors throughout the course of the pandemic and also how that has impacted. We've talked a bit about how it's impacted patients, but also how it has impacted staff and, um, staff burnout and staff moral distress. Dr. Brown or Dr Lehman, Would you like to our Miss Lemon? Yeah, you know. So the whole visitor thing was it's clearly, I mean, impacted the patients and families, but I think you hit a you know, kind of the nail on that, you know, something that wasn't fully appreciated was the magnitude of the impact this would have on the staff. I mean, we didn't go into this to just treat a bunch of numbers or something like that. We went in there to care for patients, and that's interacting with the patients. The family, etcetera, is all part of the package. And so, you know, and then how how the perception of this, um, changes depending upon what role your plane in it. So it has been a huge, um, issue to deal with. I hope we've gained some positives out of this. Not every individual, even pre covid, had the same degree of access to patients and family members. And, you know, I guess if I try and find some silver linings in this, it's the ability, the increased ability of people to have had their kids or grandkids show them how to get on facetime or zoom or whatever. And they're coming in with some of these skill sets now that weren't there previously. And I just hope that we can take the good out of this and spread that into the future. But I have no doubt that this is part of the male. Ooh, that's contributing to the increased stress of health care providers at all. So another question that has come in has been about how we have dealt with procedures and adjusting our procedural practice. And there have been many, many adjustments over the course of the past year in terms of downshifting and up shifting, Um, how much were able to, um, meet the needs of out patients or patients who are coming for more, the more elective portion of our practice or portion that could potentially be deferred by a short period of time. And I know that this has been dealt with in different practice groups, um, in different ways as well. And so I was wondering if maybe we could talk about how our teams in particular say our surgical or other procedural teams have gone about, um, triaging their own cases and trying to think about how to meet the needs of the patients who have the most urgent requirement for our care and then also how we've communicated that. I think that's a really important part and continuing to, um, Foster trust in our in our organization that we're not abandoning patients. Um, even if we have to defer their care. So any any reflections on that Dr Brown? Yeah. So thankfully, we are in an environment that we have communication that is not siloed. So we have very close relations with the hospital practice with the procedural practice, etcetera, and we know we can predict you know we have good metrics to understand if you're coming in for procedure. X done by procedural ist why we anticipate that you're going to, based on past experience. Spent 2.5 days in the ICU in a hospital length of stay of seven days, and we take that information and compare that to what the availability of our facilities are to support that type of practice and the procedural practice was ramped down, then ramped back up. And it was a you know how many you can schedule 80% something, you know, 70%. A lot of this had to do with favoring initially. Outpatient procedures are those with less inpatient requirements, etcetera, and so we can dial that up and down on a weekly basis in response to covid or whatever other stressors are out. There be an employee absences et cetera, and again so we can modulate that, uh, to a large extent. And I think that without that ability, you're kind of driving, not with your headlights on it. It's difficult to try and predict. You know how you can do that. And how do you prioritize one over another? And again, that's that's what That's where you bring in your modeling people, et cetera. And then in parallel with that, the communication strategies you just articulated that we're not abandoning you. We are attempting to provide care in a safe manner as possible, and so that when you are able to come here that we are doing our best to ensure that you've got a safe experience here and that we have the resources to provide to you what what you're going to need when you're here. And so that's really been something I don't think has been as well publicised internally here and to an external audience. The efforts that are behind that Yeah, and I think I have found that of patients I know whose care, um, say a procedure or outpatient evaluation has needed to be delayed. There's been an appreciation for the fact that, um, they, you know, an understanding. As so many people have learned the power of patience and understanding and in this past year, but also an appreciation for and, you know, trying to preserve their safety, that we don't want to bring them into the hospital at a time when it might be less safe for them and when we might have a harder time meeting their demands for an inpatient stay, for instance. And so in general, people have met that news with generosity of spirit, so that's been really helpful. I'm seeing a lot of questions come in through the Q and A about, um, allocation of scarce resources. And I think that's something that is a question on a lot of people's minds. And I I'd like to at least start that conversation. If others want to jump in. I'm happy to have other Panelists contribute to these comments. So one of the comments or questions from Dr Keith Mansell, a former colleague of ours, Hi Dr Mansell, um, was around what Mayo had done in terms of preparedness for scarce resource allocation or triage. And, uh, were we to reach a point where we were really in a crisis standard of care and could no longer meet the needs of all patients who are presenting with acute illness and might need to think about the extremely difficult conversations around prioritizing patients for access to the ICU or for specific resource if it were a shortage of ventilators, which is probably the most commonly cited example of this. And so, yes, I would say that we have both within our walls, uh, in male clinic and across the various sites worked really collaboratively over this past year to, um, stand up a much more robust response to those types of situations. Then we had coming into the year of 2020. Um, I think, like many other places, a lot of our emphasis in the past have been around masks preparing for mass casualty events or an event that might be a relatively short duration. And even early in the pandemic, I think most institutions were preparing for a relatively short surge. And as the months have worn on, we've realized the need for sustainability in our adaptations. And so, um, with that, we have continued to adapt our plans and, um so that has both occurred in within the walls of our institution, but then also each of our destination site. So in Florida, Arizona and Minnesota, there has also been extra mural collaboration with the different institutions neighboring institutions. And that is of key importance because anyone hospital doesn't serve patients in isolation. And in fact we are neighbors and need to be good neighbors to other hospitals in our regions, in our states. Um, so I can speak most specifically to the efforts in Minnesota, of which I have been a part. I have been, uh, Dr Brown and Miss Lehman have also represented us in other capacities with, um, mechanisms that have been stood up in this past year for communication and collaboration, both amongst intensive ist so intensive care practices, but also amongst ethicists to help develop, um reasonable, fair, equitable, um, schema for allocating scarce resources or critical care resources. We've also worked on things like allocating, um, the outpatient monoclonal antibodies or remdesivir. Um, and all of that, at least in Minnesota, has been done on a state level with representation from our institution and other institutions around the state. And then, um kind of, um, operationalized here locally. And, um, that's a key concept from today's webinar. That I do want to emphasize is that importance of regional collaboration because what would be a true tragedy would be if hospital found itself so stretched and so strained that it was unable to meet the needs of all critically ill patients and actually thought about things like withholding life sustaining therapies from one patient. When down the street, five miles there was another institution that still had a few beds and could have met the needs of those patients. Were there better communication? And so that by level, bi directional communication has been a key portion of the infrastructure that's been built up existed to a certain extent before 2020 and has been built up much more robustly through the course of this year. And in step with that also collaboration in drafting ethical frameworks that are more appropriate to the current crisis that earn as opposed to kind of more of a generic situation, like a mass casualty event from a train derailment or something like that that we're really trying to think very intentionally about this pandemic and these challenges that we're facing, Um, any other comments or additional points to make on that front? Doctor Brown. Yeah, I would just emphasize you said it was one of the points to get across. Here is the regional nature of this, and that's not only for trying to come up with the schema of prioritization. It's also an awareness, so we do Minnesota is fortunate to have a group that includes all of the major health systems that collaborates and basically shares information to have an understanding of capacity is etcetera, and there is a mechanism by which, if particular system is overwhelmed, that it's defined how the process works. You call the central number that's run by the state, and they will help find a bed for that particular patient. So hopefully we don't have to employ these prioritization schema that have been developed to address exactly the point that you are bringing up. And, you know, I feel badly for individuals that are on this call that don't have such a process that they can lean on in these types of scenarios. But I would submit that we need to that we need these kind of systems because, well, I hope that we can see the end of covid. I'm sure there's another virus somewhere that is thinking about trying to make that transition, and it's a matter of time before restrained in some capacity in the future. So hopefully we can learn from this. I think another thing to add would be that in addition to coming up with written documents, frameworks that are very carefully vetted. There's a huge gap between an ethical framework and the bedside, Uh, and so and not only that, but most of the frameworks that we have drafted really pertain mostly to crisis. Standard of care where you don't have enough, say ICU beds and ventilators to meet the needs of all the patients. And as I started this webinar we have most places in the country have been existing in some form of contingency for many months, where we're having to adapt and change and conserved, um, in ways that we are that were previously unfamiliar to us. And there is a great, um, challenge to doing that in a way that is also consistent, fair, equitable, transparent because there might be situations in which, in your institution, there aren't enough dialysis nurses to meet the needs of a few dialysis patients who need urgent treatment in the course of the next 12 hours. And so you might have to make relative prioritization, um, decisions and temporize one while you treat another and and how you make those decisions is a really challenging process that has been, I think, less codified in policies and procedures that have been written across the country. And one thing that we have really, um, I wanted to do is create a process Where, um should we reach a tempo of those types of decisions in our own daily practice that we really needed to, um, make those relative prioritization decisions. Not that Person X wouldn't ever receive dialysis, but that there might be a delay and that we might need to treat them medically for a few more hours, things like that if there is a situation in which there isn't a stark decision. But there is a something that feels a little bit uncomfortable or feels like bedside rationing, um, or ad hoc decision making that there. There's always the opportunity to call in a colleague and ask another. Ask for a second opinion and even to ask that colleague to document that second opinion if it feels like a substantial enough decision. And so those are some things that we have talked about doing. Should we need to? Should we be facing a situation like that again in the future? Here at Mayo, we have such a large critical care practice that we even have right now a critical care lead who is a senior clinician who can help to, um, have a bird's eye view of the entire practice and also feed information about scarcity that's being faced at the bedside up the chain of command very quickly. So those scarcities can be addressed and mitigated, Um, in an urgent manner. Um, but we recognize that many practices would not have a sufficient pool of clinicians to or sufficiently large, intensive care practice that they might be able to do that. And that's That's one way in which we have, as a very large practice, been able to, um, kind of adapt to the relative peaks and our surge. And the other thing I would say is that there has in in our frameworks and across the country been a real emphasis on removing the stark decisions. One of the questions that came in was around allocation or reallocation and mechanical ventilators. Um, and there's been a real emphasis on taking those decisions out of the hands of the bedside. Providers to, you know, allow us as providers to have that vitally important doctor, physician or physician patient relationship and advocate for our own patients and any allocation decision to be removed. And along those lines we are. We have been training a team of other individuals who in general don't practice in the intensive care unit. But practice in acute care settings, um, to populate a triage team. And we continue to, um, to meet with them and have simulations with them so that they can perform some of those duties, um, and and allow the bedside clinicians to the do the very important work of caring for their own patients. There have been some questions about support for staff, um, and the concept of moral injury. Uh, I see one of the questions is around PTSD, Um, and although I can answer a little bit because I'm help volunteer, are there any other comments before before I jump in and and address that question? Erin, I've got something, and I probably should have given you a heads up on it before asking it over the phone. But, you know, one of the things I think we've seen is that the at least in the Midwest is it's not been a bed or a ventilator or dialysis machine. That's been more staffing related issues. Staff need to be out on quarantine, family members on quarantine and therefore yeah, so related to staffing. And there's a variety of ways that you can amplify your staff and go. You know, these things go by different names. Team based nursing, etcetera. How do you What advice do you give to people to keep? A I don't want to say a handle on that, but an awareness on that because they're talking about staff distress if you're asking somebody that maybe doesn't typically work in an environment with acute Leo patients, or maybe they are a Culio, but not in that environment. And now you're asking them to do a different type of care, different model of care, etcetera. It seems to me that we really need to have a mechanism that we aren't just putting. People are not just widgets. You just can't take the outpatient person that does X and ask them to do. Why in the inpatient settings, sometimes it works. Sometimes it doesn't. How do you recommend people keep an eye on that and not sink the entire ship, trying to increase your ability to care for the maximum number of patients you believe that you can Yeah, I think that's a really important point, particularly. We've turned our attention to that a little bit more in the past few months in Minnesota, trying to not only, um, determine how many the sheer volume of patients that we can care for. But also, um, there's a renewed emphasis, at least in the, um, ethics group that I've been meeting with, um, and tracking outcomes because what you want is to make sure that your outcomes are or the care that you're providing to patients during contingency, um, conditions would be functionally equivalent. So you have the expectation of having the same types of outcomes. Maybe there would be a slight difference. And certainly there would be a big difference in the way that care looks. If the care is provided, say, and a pack you instead of in a conventional eyes you, um Or if it's a different team of nurses who are potentially, um, working as, um, you know, under the authority or under the supervision of a seasoned ICU nurse. Um, and the same goes for, of course, um, physicians where we might, uh, and have seen throughout the pandemic redeployment of people from different areas of practice, from anesthesia or from outpatient medicine into inpatient settings. But under the umbrella of, uh, seasoned acute care clinician, it's really important that we're tracking outcomes and making sure that we're still meaning, Um uh, meeting benchmarks are approximating benchmarks that we had before. We certainly don't want to, um, close our doors and say we can't take on more patients and and, you know, part of part of what we want to do is to demonstrate that we're still meaning the same type of quality of providing quality of care, but also feeding that back to the other aspects of the overall institution and our practice. It gets back to what we were speaking about towards the beginning of the call about ramping down, um, elective procedures or things like that if we're not able to, um, meet the needs of the acutely ill patients in the inpatient setting. Um and so I think there is a potential for erosion and quality when we're asking people to perform well outside of their normal scope of practice. And also, um, certainly not only for seasoned the soup clinicians, um, who have faced the type of moral distress in 2020 that they couldn't have imagined before. But also for people who really didn't sign up to work in an ICU and are kind of find themselves plunked down in the middle of a crisis. Um, how do we best support them? I know that here we have a lot of institutional support that existed before the pandemic. And that has been, um, you know, injected with additional resources, including we have a group of trained peer supporters from across disciplines who are able to, um, respond within 24 hours if an individual or a colleague uh suggests that there is a person, um, no matter what their work description from a given work area, who needs, you know, outreach and who seems to be in trouble. And, um so that's been a really powerful, uh, way of supporting our peers. And I was recruited to join that program just this year that there had been a basil level of activity of those peer supporters before. Um, 2020. But there's been I don't know how many fold increase in the number of peer supporters that they've had and and what it really is is also a rapid mechanism to plug people into employee assistance and counseling. Confidential counseling. Um, so not that our peer support team could take the place of a professional counselor, but so that we could quickly support reach out offer, um, you know, offer supporting word, um, and comfort as we plug people in and make sure that nobody feels abandoned during a very isolating and stressful time. Would it be okay if I make a comment? Yes, please. Um, I also believe that one important thing that it has been happening, I believe through our critical care practice. At least, um, there's a lot of validation, um, about like, how people are feeling in about what we're seeing. And this is not our day to day practice. This is not like a pandemic is not normal. Um, so I also believe for the people like, I see a lot of questions and comments on the Q and A like, if you're not in a place like meal where we are very fortunate to have PP for everybody that we are fortunate enough to have Like Dr Brown said earlier, people to pull from different sides of the practice that were maybe lower in in need when when things were were a big problem. Just make sure that you validate your colleagues that are suffering. Make sure that they understand they're being heard. Um, and try to try to do the best you can to be a peer support it also because people people should be validated to feel whatever they're feeling. Um, again, some of us feel feel actually very blessed to be an intensive is doing a pandemic. But some people really do not sign up for this. And I just wanted to add to the to the crisis mode, Um, because I see that we have people from all over the world Someone said hello from Bangladesh. So thank you for listening to what we have to say. Um, and I am very sensitive that I am from a Third World country, and I trained there and I was an intensive. It's their first before being here. Some places just have to be in crisis mode, no matter what. And unfortunately, the trauma literature at L s and trauma and multi multi casualty trauma also guides the practice that unfortunately, sometimes you have to do a quick assessment and make sure that you were attending to the person who has the highest likelihood of making out of that crisis. So again, shout out to all of our colleagues in L. A. And in countries that are not as blessed as we are here at Mayo Clinic. So you're doing the best you can just want to make sure that people understand that. Thank you, Dr Gallo. I think that, actually, um, is a wonderful segue into one of the questions that came in through the chat. There have been so many and looking at the time, I know that we won't be able to address all of them. And I'm so sorry for that because there are a lot of really interesting questions that we wish we had more time to address. Um, there was a question around, um, making prioritization decisions are actually kind of empowering outpatient or pre hospital providers MTs to making decisions about who would be transported first or who would be who would be treated at a hospital and who wouldn't wouldn't be transported to a hospital. Um, I think that that the comment This is a really challenging point, because if there are x number of calls going out and only a limited number of, um emergency management personnel available to respond to the calls, there does have to be, from a pragmatic standpoint, a utilitarian standpoint. Um, there has to be some judgment and how to respond to, um, the the needs of patients that said, um, you want, Especially when the decision is a stark decision that might result in a death if the patient and in fact maybe is likely to result in death or severe morbidity if the patient isn't transported to the hospital, you would want that decision to be made with the best possible degree of knowledge. And that's a lot of what we've struggled with. Even if you think about if all those patients were to arrive at the doors of a hospital, what can we use to expeditiously look at all comers and determine who would be likely to benefit? Um, and likely to survive a hospitalization, Um, and who is too ill to even, um two to be granted access to an ICU If you are in a situation where you have too many patients and not enough ICU beds. Um, and so I guess what I would say to that not meaning to cast judgment on the port, Uh, first responders who are in a terrible situation to have to face that type of responsibility and decision that to the best of our ability, giving due process to all patients and providing as much information, uh, and supporting clinical decisions about who receives resources access to resources first with as as much clinical information and judgment as robust as possible. You know, this is kind of the definition of a bedside triage, but in a situation where, um, conditions are so austere that you might not really have any, um, ancillary information or testing to help stratify patients. And that is, um, it's just a chilling thing to think about. And yet we all know that our best laid plans for what happens in the neat and orderly world of a hospital are don't necessarily translate into the real world. Any additional comments from our panel there? Okay, um, there have been questions, too, about, um, inequity and, um uh, in our methods of communication and whether use of, say, videoconferencing exacerbates initial additional or existing inequities and I know, Dr Gallo, you and I have talked about this Quite a bit, actually. Are early observations were of, you know, the number of interpreters tablet interpreters being used in our I. C. U s just exploding as the early surge happened. Um, in a way that was really noticeable to all the people on the front lines. So maybe you can speak a little bit to this. Um, I Yeah, we had we have noticed, um, and Mayo also, and, um, all over the country and the world that health disparities were actually brought to light during this pandemic. And, um, one of I've answered one of the questions in the in the Q and A box already. But I believe that having an interpreter, whatever way you could have either iPad or in person was a huge thing. It helped tremendously for family members and patients who were still able to talk to us, understand what was happening and understand prognosis. Um, so I would say if you have an interpreter, um, available either in person or iPad. Huge help. Um, I know that there were some hospitals that also noticed that some some, um, health disparities involved patients who could not even afford a tablet or could not afford a smartphone. Um, and I know of some hospitals I believe in New York, and I believe, also in Florida that provided ipads, um, tablets, Um, uh, to the family members so they could take home and talk to their patients, talk to their family members and the and the health care team. Also, um, we we were fortunate again, very fortunate to have most of our patients and and or their family members had smartphones. So when we were not able to to use, um, the technology that we had from male to call them, we asked family members to call from their own, um smartphones. So we could also have have family conferences. And but again, I think using using an interpreter as much and as often as you can was very helpful. There are some questions in the chat around how we now adjust and kind of regain our footing if we're so fortunate to be, um, in a position where the worst is behind us, which obviously history will tell if that is the case. But, um, you know, it's it's a very difficult thing to adjust our operations to an uncertain future. And Miss Lemon, you have led us through all of that. Um and and I think a question that we wanted to maybe leave the group with was around How we kind of pivot and look toward the future and acknowledge to, um, again looking at the number of um, comments in the Q and A about burn out and the sacrifices that people have made over the course of 2020 that we can't just turn on a dime and go right back to the way things were without acknowledging the sacrifices that people have made and the losses they have witnessed and the losses they themselves have suffered. Um, so maybe Miss Lemon, if you can start by talking about how we make that transition and then if anybody else on the panel wants to add, I would welcome anyone else's comments on this. But we have. We're having a lot of conversation about the hybrid model that we are now in and will likely be in for the rest of this year and and who knows? Beyond that, But we do have patients who have been waiting for our help, right? So we must continue to bring them back to the practice. You know, have our surgical practice at the highest level of capacity that we feel like is reasonable while maintaining our resources and our of course dedication to covid patients and and the rest of our normal census. Um, but it's really going to be continued to be a matter of prioritization from my perspective. And we are going to have to be flexible when either of those becomes gets to a point where we have to move resources, um, or allocate things differently to meet those demands before handing off. I'll just say I feel like so much of our discussion today and really just around Covid emphasizes the intricacies of the full care continuum and so to me, um, you know, it's not just an understanding of the downstream impact. We've talked about the surgical practice and therefore the ICU care and resources that are required but upstream, the outpatient practice having to match their capacity to demand, but also their capacity to the capacity of other resources and services that we offer. Um, neither of those can be out of balance and so as leaders. The onus is on us, right to look at that full picture and make sure again that we are prioritizing and moving ourselves in the direction to match whatever the need is at that particular point in time. That, to me, is where we will be living going forward and how we will take the lessons learned from Covid and continue to advance the practice in new directions. Dr. Brown and others would welcome additional comments. Yeah, that's what I was trying to intimate earlier is really That's the position that we're in right now. And we're going to be in this position, I believe, for the foreseeable future. I mean, obviously, we're trying to plan for a scenario when Covid is, you know, in the history books, et cetera. But I don't I believe that all health systems are going to have continuing stressors that are going to push them to operate at high capacity to continue to provide high quality care. And the more information is power when it comes to trying to figure out how to do that. So maintain your contacts within your you know, your health systems, so you are able to speak up and identify what are going to potentially be bottlenecks and how you can help mitigate, um, those as well. So thank you so much. It's been wonderful having everybody on the panel participate, and we really appreciate the engagement from our webinar audience as well. Theresa, I think you had some final words that you would like to share with us. Thank you. Yes, thank you, everyone to joining for joining us today and discussing managing ICU capacity and ethics and crisis care. If you did enjoy today's discussion, we'd like you to check out the future topics that will have it registered for any of these upcoming webinars. And again as a reminder. If you'd like to claim credit for today's webinar, please visit ce dot mayo dot e d u slash covid 0217 You'll need to log into the site, and if it's your first time visiting, you'll need to create an account. And after you've done this and logged in, you'll be able to see this access code box pictured here in the middle of the screen. You want to type in today's code and remember, this is case sensitive. So all caps. Covid 0217 And this will allow you to access the course, complete a short evaluation, and then you'll be able to print or download your certificate. So once again, thank you for joining us today. And we look forward to seeing you all at the next session, okay?
