Meeting an Overwhelming Challenge

Andrew Goodwin, M.D., MSCR

by Kat Hendrix, Ph.D.

The first weeks of the pandemic delivered a small but vital gift to those charged with leading the MUSC response. That gift was time. The novel coronavirus that causes COVID-19 appeared in California and New York in early March, but it was another month before it reached all 46 counties in South Carolina. That brief lag gave MUSC’s team a head start on designing what would be a successful, albeit exhausting response. Andrew Goodwin, M.D., an associate professor of pulmonary and critical care medicine, helped lead an effort that involved multiple areas across the MUSC enterprise. “We realized early on that we had to overhaul the usual ways we provided care. So, first and foremost, we had to get all the right stakeholders in the room. That was when we realized what an overwhelming amount of change it would require to care for our COVID patients and maintain a safe environment for our staff and other patients,” says Goodwin.

The departments of pediatrics and obstetrics had moved into the new MUSC Shawn Jenkins Children’s Hospital and Pearl Tourville Women’s Pavilion in February, making space available in the main hospital for expanded capacity, but the devil was in the details. “The first challenge was that it is an older building and different units share air handlers. To minimize risk of airborne transmission, we had to figure out where we could segregate airflow between areas,” says Goodwin. “Every department came together — facilities, operations, emergency management, the ICU (intensive care unit) — and we literally started by going through air duct blueprints to see where air handling was shared and where it would not circulate out of a COVID area.”

After identifying two vacant clinical units with segregated airflow — the pediatric cardiac ICU and a newborn nursery — the team began converting them into COVID treatment areas. The facility staff, led by Iggy Pla, reengineered the units into negative-pressure areas where air from inside is blown outdoors, while others redesigned processes of care to meet the realities of treating COVID patients. “The old pediatric cardiac ICU was an open-bay design with only a curtain between beds,” says Goodwin. “We had to figure out how to care for critically ill adults in an open situation where some patients are awake and conscious while others are sedated on respiratory support. We had to think about providing privacy and bathroom access and how to get them out of bed and mobilized in that environment.”

Converting the newborn nursery presented different challenges. “It was designed for babies in bassinets, which don’t take much space or need a lot of equipment. We had to figure out how to fit adult hospital beds and ICU equipment into a really confined area,” explains Goodwin.

Every activity required careful consideration. Where would staff don and doff personal protective equipment (PPE)? How would staff inside a COVID unit communicate with those outside? The team also adopted a green/yellow/red coding system to indicate required precautions for every hospital area. Red designated areas for direct COVID patient care. Goodwin says, “It’s difficult to communicate in a red area, because you’re completely covered in a full face shield, mask and gown. The Center for Telehealth loaned us several video stations, which helped considerably. We mounted them inside the rooms so we could communicate with staff outside and have face-to-face video discussions with patients inside without having to put on full PPE. That was really important in helping us conserve PPE, particularly early in the pandemic, when supply chains were disrupted nationwide.”

Treating non-COVID patients was also a concern, since MUSC continued to provide care to patients with other medical conditions whose COVID status was unknown. “We had to create workflows to manage patients while we waited for their test results. Again, everyone got together and really thought through how to keep our staff and other patients safe,” says Goodwin.

Because the virus was entirely new, a multidisciplinary team was formed to determine what standards of care should be implemented. “Developing consensus on how to care for these patients was a big initiative,” says Goodwin. “From a provider perspective, it was unnerving to see practitioners in some centers around the country advocating treatments that were not recognized as the standard of critical care. I think many felt a compulsion to do something, even if it was unproven, to try to help their patients. Here at MUSC, we believed it was important to tune out the noise and develop a plan that didn’t abandon good critical care practices — what medications to use, how to use our life support modalities, making sure our patients had access to rehabilitative care as they improved. Fortunately, over the course of the pandemic, we’ve been able to incorporate new evidence from valid, rigorous studies as it has emerged.”

Despite the successful organizational efforts, Goodwin recognizes the intense stress on providers. “I worry most about how much burnout we’ll see from this. It’s overwhelming to have so many patients who are all so critically ill at once. It really attacks the spirit to see so many people that sick. The strain is tremendous, especially for nurses, who do most of the bedside communication. It’s anguishing to tell families how sick their loved one is and that you’re sorry they can’t see them, even if there’s a high likelihood of death. I worry about the long-term health of all the providers who are dealing with this.”

Still, there have been moments of hope when the team sees their dedication and determination pay off. “We’ve had successes, too,” says Goodwin. “Some early reports suggested that 85% of ventilated COVID patients didn’t survive — that was terrifying. So when we extubated our first three patients — when we got them through their respiratory failure and their lungs healed enough to get them off the vent — that was really a joyous moment. We saw that when we stuck to our good critical care formula, people could survive. It gave us a lot of hope.”

Staff also successfully cross-trained and built new care teams. “Like most places, we had to draw physicians and nurses from multiple areas, including people who’d never worked together before. It’s gratifying and inspiring to see a real esprit de corps: nurses from one ICU teaching nurses from another how to do something they may have had more experience with. Everyone is dedicated to getting this right and helping each other even in this incredibly stressful situation,” says Goodwin. “The MUSC vaccine rollout is another notable success. It’s going exceedingly well here. Logistical planning by Danielle Scheurer and her team has been excellent, and the sign-up is easy. People who are supposed to get it are getting it.”

This experience will also produce future benefits. “MUSC is planning to expand our critical care footprint by keeping open some areas we’ve been using for critical care treatment after the pandemic. Expanding critical care access benefits the entire state,” says Goodwin. “We also hope to harness the cross-unit teamwork to our advantage. Everyone did a lot of work to create a really good playbook for future crisis responses, and we’ll be more forward thinking as we update or build new care areas. We certainly won’t have to start with blueprints to separate air flow again.”