COVID SWAT Teams

As emergency rooms and intensive care units (ICUs) became overwhelmed with COVID-19 patients in late March and early April, the need for catheters—which have uses that include delivering life-saving medications and fluids directly to large veins and arteries—has exploded.  

Every patient who is intubated, or placed on a ventilator, requires one or more catheters, which are also called lines. The unprecedented need for line placement in COVID-19 patients has created another need—physicians who have the skills and time to perform the procedure. 

In a unique partnership, interventional radiologists from the Department of Radiology at Columbia University Irving Medical Center and NewYork-Presbyterian Hospital have partnered with members of the Department of Surgery to place lines quickly and efficiently in COVID-19 patients. Called Surgical Workforce Access Teams—or COVID SWAT teams for short—three groups of physicians and residents at two hospitals are on call and ready with all the necessary equipment, including high-quality ultrasound, to place lines at a patient’s bedside.  

“Due to Covid-19, the hospital had to double its ICU capacity. For many doctors who were redeployed to the newly created ICUs, placing lines was not part of their usual practice,” said Vladimir Sheynzon, MD, assistant professor of radiology at Columbia University Irving Medical Center, who helped form and lead the interventional radiology division’s involvement in the SWAT teams. “It became necessary to bridge that gap with people who have the skills.”

“These are not simple procedures,” he added.

Catheters are long, soft tubes that provide direct access to veins and arteries. They have several uses in the ICU. Central venous catheters (also called central lines) are used to deliver fluids or antibiotics directly to a large (central) vein in the neck, upper chest, or groin. All intubated patients need central lines. In addition, 30 percent of critically ill COVID-19 patients also need dialysis catheters, which allow blood to flow into a dialysis machine and back into the body. A third type of catheter, called an arterial line, is placed in the artery and used to monitor blood pressure in real time.

Placing catheters is common practice for interventional radiologists, who use image guidance to perform minimally invasive procedures that often serve as an alternative to open surgery. In normal times, however, the procedure takes place in a dedicated interventional radiology procedure room.

There are too many very ill patients now. “It would be extremely inefficient to bring patients to interventional radiology to place the lines,” said Dr. Sheynzon explaining that each intubated patient would have to be transported in an ICU bed, with a ventilator, monitoring equipment, and IV pumps, tying up valuable resources—including doctors, nurses, and respiratory therapists—just to move the patient from one part of the hospital to another. In addition, the procedure room would have to disinfected after each procedure. "It would take two hours. It would also be perilous to the patient and the staff.”

A procedure for placing lines at patients’ bedsides was implemented by physicians in Columbia’s Department of Surgery in late March. But its success depended in part on having enough attending and resident physicians to perform these bedside procedures. As COVID-19 related admissions mounted, the team was straining to meet the surging demand.

At the same time, interventional radiology was seeing a decrease in patient volume. All elective procedures had been postponed and interventional radiology nurses had been redeployed to the ICU. Residents had also been redeployed but were performing mostly administrative tasks.

“We have this unique skill and we also had time,” said Dr. Sheynzon. “We said we’re going to join you guys and make it work. Our senior residents are well trained. Under attending supervision, they are capable of fulfilling the role on the COVID SWAT teams.”

And because interventional radiology uses imaging to guide every procedure, they were also able to offer a higher quality ultrasound for physicians placing the lines.

With his interventional radiology colleagues, Dr. Sheynzon joined forces with Dr. Beth Hochman and Dr. Tracey Arnell from the Department of Surgery to incorporate interventional radiology into COVID SWAT Teams. Three teams were created, each made up of an attending physician and several residents. Two teams work at Milstein Hospital on 168^th Street and one at the Allen Hospital at 218^th Street—both part of the NewYork-Presbyterian Hospital network.

“There was no interventional radiology at Allen Hospital,” said Dr. Sheynzon. “We found supplies in the operating rooms. We had to figure out where everything was.”

Within 24 hours, the Allen SWAT team was ready for deployment.

Now, when a line placement is needed, teams are contacted by pager or through a secure online chat that is connected to the electronic health record. The team who is available and closest to the patient is deployed. SWAT bags are ready with all necessary equipment, as are portable ultrasound machines borrowed from the Department of Radiology.

“We are able to respond almost immediately and place the line within 30 minutes of the request,” said Dr. Sheynzon.

The SWAT teams have formalized operating guidelines, which were initially developed by Drs. Arnell and Hochman. Guidelines are amended regularly by both surgical and IR team members as the teams gain operational experience. The guidelines include everything from how long to wait after a patient has been intubated before entering a negative pressure room in order to preserve N95 masks, to a tutorial on how to confirm venous placement.

Dr. Sheynzon and his colleagues have shared their process with other institutions in Westchester, Connecticut, and New York City.