IN THE NEWS
JUNE 2021 / GENERAL SURGERY NEWS
How Acute Care Surgery Team Managed the COVID-19 Surge By VICTORIA STERN
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hen COVID-19 began to surge in the United States in March 2020, hospitals had to act quickly. The acute care surgery (ACS) team at Tufts Medical Center, in Boston, was no exception. “We felt a sense of urgency to prepare our hospital for an influx of critically ill patients,” said Horacio M. Hojman, MD, the chief of the Division of Trauma and Acute Care Surgery and surgical director of the Surgical Intensive Care Unit at Tufts University School of Medicine. “As trauma surgeons, we see emergencies every day and are trained to come up with a plan fast.” Despite limited information about the coronavirus, the four-surgeon team quickly pivoted their normal operations to meet the moment. First, the surgeons devised a system to separate COVID-19‒positive and uninfected patients into two surgical ICUs, and to provide around-the-clock coverage of trauma, emergency general surgery and surgical critical care patients, leaving a handful of surgeons in reserve in case anyone got sick. “Many of those systems were created on the spot by extrapolating from our disaster preparedness plan deployed during the Boston Marathon bombing, military training, and the experiences our colleagues in Italy and China had with COVID19 even earlier in the pandemic,” said Nikolay Bugaev, MD, the executive director of research in the Department of Surgery and an assistant professor of surgery at Tufts University School of Medicine. “We saw our colleagues across the country and the world facing a similar challenge, and decided to document our experience to understand how well our disaster planning worked.” In late November, Drs. Hojman and Bugaev, and their colleagues published a review comparing patient demographics, needs and outcomes two months before and after the March 2020 COVID-19 surge to assess their system and provide a guide for others (Am Surg 2020;86[12]:1629-1635). The authors found that during the initial surge months, trauma and emergency general surgery volumes at Tufts dropped by about 51% overall, while critically ill patient volumes increased by 64%. Between March and May, the needs of patients admitted to the ICU also shifted. Overall, the majority of people admitted to the surgical ICU were not surgical patients. The surgeons tracked the types of procedures performed and reported that, in the months before COVID-19 hit, emergent laparotomies were the most common procedure encountered by the ACS team (35%), but during the surge that shifted to tracheostomies and percutaneous endoscopic gastrostomies (36%).
To protect clinicians from aerosolized particles during tracheostomies, the surgeons created a localized negative-pressure environment by overlaying the top of the bed with a plastic, nonsterile sheet and connecting an air filter (Am Surg 2020 Dec 7). Of note, the surgeons found that hospital mortality did not differ significantly between the pre‒COVID-19 and surge groups (9.6% vs. 13.4%, respectively; P=0.4) or between critically ill COVID-19
patients treated by ACS and non-ACS ICUs during the surge (13.4% vs. 13.5%, respectively). “I was pleased at our great results,” Dr. Bugaev said. “The ACS service was able to apply general emergency concepts and escalate them rapidly in order to continue providing trauma and emergent surgical services during the surge, while also delivering intensive medical care to nonsurgical patients.” Six weeks into the new system, the influx
of COVID-19‒positive patients began to plateau and the ACS service gradually deescalated its disaster plan. With this experience, Drs. Hojman and Bugaev now feel prepared if there is a next time. “After creating and implementing this self-sustaining emergency plan, I think we’re better equipped to handle an emergency of this magnitude,” Dr. Hojman said. “We were lucky that our expertise managing disaster scenarios could be put to good ■ use during the pandemic.”
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