Article In Brief
Major academic neurology departments had to plan to redeploy on the front lines of the COVID-19 pandemic. Here is what they've had to do to prepare for the surge in cases.
On March 24, physicians and other health professionals in New York State received a letter from Commissioner of Health Howard Zucker, MD, seeking emergency help in responding to the COVID-19 pandemic in the state.
“We desperately need more qualified health professionals to supplement our hospital capacity on a temporary basis,” he wrote. “I am asking licensed professionals like you to lend your clinical expertise and experience during this public health emergency...I am also asking that you alert current and former colleagues and retired healthcare professionals of this need and call to service. We need physicians, nurses, nurse practitioners, physician assistants, respiratory therapists, EMTs, and other frontline medical personnel. We welcome those who licenses have expired, whether recently or long ago, because experience and skills are what matter right now. New York State will recertify these individuals for immediate deployment.”
New York was by far the hardest hit US city in the pandemic's initial wave, but health officials in other cities and states have anticipated that they too will soon experience extreme stresses on their hospital capacity and clinician workforce, as COVID-19 outbreaks increase across the country. In many hospitals, neurologists are among the specialists being asked to deploy outside of their area of specialty to areas where there is a need.
Robert Wood Johnson University Hospital
At Robert Wood Johnson University Hospital in New Brunswick, NJ, and University Hospital in Newark, the main teaching hospitals affiliated with Rutgers University, the peak of the COVID-19 patient surge is expected around mid-April, said Suhayl Dhib-Jalbut, MD, FAAN, professor and chair of neurology and Ruth Dunietz Kushner and Michael Jay Serwitz Chair in Multiple Sclerosis at Rutgers-New Jersey Medical School & Robert Wood Johnson Medical School.
The state-of-the-art neurocritical care unit on the New Brunswick campus, which was opened in May 2019, has 15 beds and is staffed by four neurocritical care neurologists.
“The plan is to consolidate floors and units for COVID patients,” Dr. Dhib-Jalbut explained. “As the surge hits, our four neurocritical care faculty will be assuming almost full care for COVID patients. Their training and expertise allow them to take care of respiratory problems including the acute respiratory distress syndrome and other complications associated with COVID.”
Neurology residents under faculty supervision are already providing consultations on COVID patients for a variety of neurological manifestations, such as encephalopathy. To minimize exposure of our residents to COVID and to save on PPEs, after the residents collect the medical information and diagnostic tests results, only the attending neurologist interacts with the patient, he said.
“But if the surge requires further redeployment of more physicians from other specialties, the residents and fellows will be the first outside of neurocritical care to be assigned,” Dr. Dhib-Jalbut added. “Unlike senior faculty who have been highly specialized and practicing subspecialized neurology for years, younger physicians are closer to their general internal medical training.”
In some instances, faculty were excused from face-to-face contact with patients due to individual high-risk factors. Instead, those faculty have been utilizing telehealth and taking more night call from their homes. “If needed, our residents and attending neurologists might become ‘first responders’ in the emergency department for patients who present with clear cut neurological symptoms,” Dr. Dhib-Jalbut said.
“It is becoming evident that this is not just a respiratory disease and affects other systems in the body,” he said. “Patients are presenting with additional symptoms such as confusion, encephalopathy, seizures, and headaches. We need to be aware that these are possible neurologic complications of COVID and that these could be among patients' early presenting symptoms. We'll be learning more about the acute and late nervous system complications of COVID-19 through imaging and other studies later on, but now there is no time for that.”
Washington University/Barnes-Jewish Hospital
In St. Louis, MO, which had an estimated 470 people hospitalized with COVID-19 and 34 deaths as of April 6, each clinical department at Barnes-Jewish Hospital has been asked to develop contingency plans and redeployment schedules to cover disease-specific pods in the emergency department if there is an emergent need.
“Early on, we had several emergency physicians who had to be quarantined because of exposure,” said Brad A. Racette, MD, FAAN, Robert Allan Finke professor and executive vice chair of neurology. “The two most critical areas right now are the emergency department and the ICUs, and those areas have very finite critical resources. As we put our plans together, one of my younger administrators, a very talented associate professor, commented, ‘I don't know if I'm doing this right. I've never done anything like this before.’ I said, ‘No one has.’”
Neurology will likely be one of the more important services to roll out a service pod in the ED should it become necessary, Dr. Racette said. “The idea is that we will relieve the need for the ED faculty and residents to be involved in the care of absolutely every patient. We are ready to go if we're needed: all vacations have been cancelled indefinitely and all faculty and residents, staff, and fellows need to be within 60 miles of St. Louis to implement the disaster plan at short notice.”
The department of neurology has a faculty of approximately 140 (including pediatric neurology and neurorehabilitation), although not all are clinical and not all are able to work in high-risk situations. The emergency plan involves assigning one available clinical faculty member to one 12-hour emergency department shift over the course of a month.
“Because of the size of our department, if we did a month of this, it would only require about half of our faculty to work in that high-risk environment,” he said. “We also would pull in two residents to cover this new service, to do 12-hour shifts along with the attending. With one attending and a resident, it would be structured as its own consult service.”
The hospital's neurologic intensive care unit, which contains up to 44 beds, is also being repurposed to deal with COVID-19. “All elective admissions have been cancelled, and our neuro-ICU physicians, nurse practitioners and fellows are in a pool that are likely to be called upon to assist with COVID patients in one of those units,” Dr. Racette explained. “The ICU is likely to be our first pressure point where neurology is called upon to work outside of our focus area.”
Rush University Medical Center, Illinois
Illinois Governor J.B. Pritzker issued his “stay-at-home” order on March 21, just a day after New York Governor Andrew Cuomo did the same for his state, but the peak of cases is expected to hit the state much later. Peak use of resources and peak daily deaths in Illinois, according to the University of Washington's Institute for Health Metrics and Evaluation, will be on April 20 (compared with April 9-10 in New York).
Rush University Medical Center currently has 76 patients in its intensive care units with COVID. “We keep opening up new ICUs as needed in different areas of the hospital,” said Movement Disorders Section Head and Parkinson's Foundation Professor of Neurology, s Deborah Hall, MD, PhD, FAAN. “We have some of the sickest patients in the state, including 25 percent of all the ventilator patients in Illinois.”
Rush's emergency tower, the Robert R. McCormick Foundation Center for Advanced Emergency Response, was designed to handle the surge of patients that could come from a terror attack or pandemic disease. The emergency department takes up the entire ground floor and sliding glass doors rather than curtains separate the 40 negative-pressure treatment rooms.
“The first-floor lobby area can also be converted for use in a large-scale emergency,” said Dr. Hall. “It was designed with a lot of flexibility; the large pillars that support the building can be opened up to reveal places to plug in ventilators, and the whole area is wired with oxygen and electricity, allowing it to be turned it into a massive patient care area.”
Rush's department of neurological sciences includes approximately 100 neurologists in eight sections. Neurology Chair Zoe Arvanitakis, MD, MS, FAAN, has tasked each section head as a point person to prepare redeployment plans for their sections.
“We've been redeploying faculty and staff on a rolling basis,” said Dr. Hall, who is leading the planning process for her section of 50 faculty and staff. “My first action was to send all faculty and staff who were appropriate to work from home. This included anyone over 60, in the third trimester of pregnancy, immunosuppressed or with chronic cardiac or lung disease.”
Dr. Hall's next task was to recommend which staff members should be redeployed to the “front lines,” working with COVID-19 patients, and who should remain in the movement disorders section where there are few live patients.
“You lose sleep over it,” she said. “You are purposely putting staff and colleagues in harm's way. How do you decide who should go and who stays behind? Although I spent a lot of sleepless nights trying to sort this through with my administrator, when I actually went to meet with our staff, several of them volunteered right away. They said, ‘I'm up for the challenge.’”
As of press time, the movement disorders section had six front-facing clinic staff members and three administrative assistants who are rotating in redeployment and two physician assistants who are fully redeployed to the emergency department. None of the section's ten clinical faculty have yet been redeployed yet.
“We expect that we are a couple of weeks away from being called upon,” Dr. Hall said. Meanwhile, she and another faculty member are covering the movement disorders inpatient service and have sent the three fellows to work from home unless they are called as part of the emergency response.
Redeployment of clinical faculty at Rush will happen in two waves, with a third only if absolutely necessary, said Sayona John, MD, head of the critical care neurology section. “The first stage deploys all of the medicine specialties to COVID care. If the first team is exhausted, the second wave deploys the subspecialties and the non-medicine specialties, like neurology and neurosurgery. A third wave, even though this hasn't been specified in writing, could be the non-clinical specialists, but hopefully we won't get to that point.”
Half of Rush's 28-bed neurocritical care unit has already been dedicated to COVID patients. “We are fortunate that, because of the way the building is structured, we have 14 beds on each side, so we have demarcated a COVID side and a non-COVID side,” Dr. John explained.
“This means that we cannot accommodate every single neurocritical care patient in the neuro-ICU, so there are now neurology patients in other ICUs that have to be managed primarily by neurosurgery or the stroke group. Our previous boundaries, in which all neurocritical patients go to the neuro-ICU, are no longer relevant. And when the surge hits, the plan is that all ICUs will have to fully convert to COVID units.”
However, she added, discussion regarding keeping the neuro-ICU a “clean unit” may change this plan and be held specifically for non-COVID neurology patients.
Unlike New York City, Chicago has had three weeks to plan, develop protocols, and train staff, Dr. John noted. “Our entire critical care staff at Rush has gone through specialized training for this pandemic,” she said.
“I have conducted at least three lectures for neurology and neurosurgery on how to manage these patients. And we have a command center on the fifth floor of the hospital that has physicians and administrators from all specialties working 24-7, with a central number you can call with any issues. They are responsible for predicting the influx of patients, making decisions about which ICU is open and where patients go, and updating the entire institution about where we stand.”
Stanford University Hospital
Santa Clara County, where Stanford University Hospital is located, was one of the first areas of the country to issue a shelter-in-place order on March 16. The stay-at-home order, still in place, affected most of the San Francisco Bay area; it was followed a few days later by a similar order for the entire state of California from Governor Gavin Newsom.
That head start has made a big difference, said Frank Longo, MD, PhD, the George E. and Lucy Becker professor and chair of the department of neurology and neurological sciences.
“Our county was one of the first to be affected and initially we had the highest numbers in California, but I think the order slowed it down in the Bay Area. During the past week, our number of COVID-positive patients in the hospital has been running from 12-15. In the last few days we've seen it tick up a little, to 17 and then 19, so maybe we're seeing the beginnings of an increase, but our numbers are very small compared with New York and other areas. At the same time, we are preparing for the possibility of high volumes.”
Stanford's stroke step-down unit has been prepared to function as a COVID ICU, as have older wards that were in various stages of renovation. “Our colleagues in medicine have done a large-scale mobilization, and other divisions have our backup plans,” Dr. Longo said. “Each division has a tiered backup system for the fellows who are typically on outpatient services to come in and do inpatient care, and attending faculty are also on backup. So far, the plan is not for us to be directly providing care for COVID patients as I know has happened in New York, but we have been asked by the department of medicine to prepare to have neurologists available who have higher levels of medicine training.”
Each division normally has one fellow and attending available to provide consultation on the inpatient side, but now that in-person outpatient care has been minimized, the divisions are each able to provide an additional fellow and attending to assist with inpatient are who would normally be working on the outpatient side.
“Stanford cancelled all elective procedures fairly early on, which has created quite a bit of capacity,” Dr. Longo said. “And though much of our outpatient care was converted to telehealth, the volumes aren't as high as normal; we are currently running at about a little over 50 percent of our normal outpatient volume.”
“The very quick adoption of virtual care has also been very helpful in minimizing exposure among our clinical teams, residents and faculty, as has the onsite COVID test that the Stanford Pathology Department diagnostic laboratories created and verified,” Dr. Longo continued.
“The capability of reaching a pretty good volume of testing early on allowed our physicians in the ED and other places to assess patients and members of the health care teams fairly quickly, which has helped further reduce internal exposure. I am impressed with how quickly people have adapted. After this is over, which hopefully will happen soon, we will have some new best practices that can be adapted for use even in ‘normal’ times.”