How Cedars-Sinai Built 'COVID Line Team' for Busy ICUs

At Cedars-Sinai, a volunteer team of experienced physicians is placing central and arterial lines in COVID-19 ICUs.

A volunteer "COVID Line Team" at a Los Angeles–based medical center has boosted the efficiency of placing central and arterial lines in COVID-19 ICUs and taken pressure off busy critical care teams.

During coronavirus patient surges, hospital ICUs often become inundated with severely ill patients. The COVID Line Team at Cedars-Sinai Medical Center has increased the efficiency of placing central and arterial lines in coronavirus patients and freed up precious time for the dedicated ICU clinical staffs.

The COVID Line Team was formed in March 2020 during the first coronavirus patient surge in Los Angeles, says the team's leader, Evan Zahn, MD, director of the Guerin Family Congenital Heart Program at Cedars-Sinai's Smidt Heart Institute.

"I sent out emails to departments where I thought the expertise was located. We had a remarkable response. We got several physicians from anesthesia, who are obviously good at placing lines. We got pediatric intensivists. We have a wonderful procedural center here, and those clinicians are super talented and have participated in a big way," he says.

With elective procedures on hold during the first coronavirus patient surge, Zahn was able to recruit nearly 20 physicians to work on the COVID Line Team, and they were able to place lines in COVID-19 ICUs around the clock. "We had anesthesiologists with tremendous skill not practicing. I was not scheduling elective cases with babies. We had the time to provide a 24/7 service, and we were heavily utilized," Zahn says.

The COVID Line Team has generated several advantages, he says.

• With experts who are efficient at placing lines, there are quicker procedure times. "The bedside nurses tell us that when they have a line that is challenging, it can take an hour or hours for an ICU clinician to get the line in. For the COVID Line Team, it is very unusual for any line to take more than 10 or 15 minutes," Zahn says.
   
• The speedy procedures free up time for ICU nurses. "They are standing there assisting us in placing lines for only a few minutes, so they can get back to taking care of patients," he says.
   
• The COVID Line Team reduces the exposure of ICU clinicians to the coronavirus. "When we walk into an isolation room, we protect the junior house staff and junior physicians from coronavirus exposure. Similarly, the ICU medical team does not have to do the donning and doffing of personal protective equipment to perform the procedure. They can be figuring out a strategy to care for the patient rather than doing the mundane tasks of putting in these lines," Zahn says.
   
• The COVID Line Team has been able to keep complications minimal. "We are a highly trained, highly experienced group that has been doing these procedures for many years. These are patients who are quite ill, and they cannot afford to have line complications. Our line complication rate has been almost nonexistent because we have such an experienced group of operators," he says.

Practice makes perfect

Utilizing the medical center's simulation center was one of the keys to success for the COVID Line Team, Zahn says.

"We did not just show up as a line team. Before we started placing lines in the ICU, we spent several days in our simulation center, which was set up to look exactly like an ICU. We worked out exactly where each piece of equipment would go and exactly how we would go into the isolation room. As with all technical things, the more planning you do, the more efficient you are," he says.

The simulation work has eased the process of adding new members to the COVID Line Team, Zahn says. "Once we had our simulation set, we created instructional videos and virtual reality for COVID lines that we could use to train our new members quickly. They could do the simulation work, watch a couple of procedures, and be ready to go."

The simulation center was also pivotal in training the COVID Line Team how to operate with cumbersome personal protective equipment, he says. "Walking around with the kind of PPE we wear to do these procedures is not a normal thing, and none of us were really experienced in that part of this work. The simulation center was invaluable. The line part was easy for us. But how you do this work and stay safe and keep the nurse safe and minimize your time in the room while maximizing your efficiency can all be achieved through simulation."

Logistics and supply chain

Robert Wong, MD, a pediatric cardiac anesthesiologist, has led the logistical effort to keep the COVID Line Team well organized, Zahn says.

"He puts out a monthly schedule for the COVID Line Team physicians. Through some of his technicians, he organizes all of the supplies, so we have all of the lines and the accessories you need to get them in. Robert has organized a supply chain, so that whenever we go to a COVID ICU, all of the supplies are readily available."

COVID Line Team metrics

The COVID Line Team has been tracking a limited set of metrics to assess quality of care and staffing issues, Zahn says. "We did not set out to do this as an academic exercise. It was much more a call to arms, and we followed very simple quality metrics that we felt were important to track."

Weekly quality meetings generated a data-driven gain early in the program, he says. "One of the things we noticed early on was that we were losing arterial lines due to thrombosis, and this was before it was widely known that these patients were hyper thrombotic. Through quality improvement, we were able to quickly heparinize lines to prevent them from clotting."

Zahn has been tracking operators, time spent in isolation rooms, and how many lines a clinician does. "I was basically asking people to stand in harm's way. I felt the responsibility of protecting the people who were risking exposure to the coronavirus, and it was important to me that nobody got over-exposed and subsequently ill. The proof is in the pudding—no one got hospital-acquired COVID on our team."

They also have been tracking utilization of central, venous, arterial, and dialysis catheters. "We noticed at a certain point that there was a marked increase in dialysis catheters, which signified that the degree of illness that we were seeing was increasing with renal failure, and we discussed this with the ICU team," he says.

Other metrics are related to staffing and physician performance, Zahn says. "We look at percentage of lines placed on weekdays versus weekends so we can meet our staffing needs. We look at the number of lines placed by junior physicians versus senior physicians to see if there is a difference in outcomes."

Related: Coronavirus: Tiered Staffing Recommended to Bolster Critical Care