Concept Map: AKI with COVID-19

Here is a concept map of early causes of AKI- what others and we have seen in NY. As you can see, tubular cause most likely but other compartments can be involved as well.

Perspective: Innovation during COVID-19

As our health system and NY and parts of US keeping getting hit with COVID-19, it is hard not to notice innovation happening rapidly.  Our health system is now cared for over 9,000 COVID inpatients and several doctors and nurses redeployed to help in this mission. What an heroic effort.

What has evolved as a result of pressured needed timely treatments?

1. Shortage of ventilators- use of CPAP machines
2. Offices closed -fastest adaption of Tele medicine in history of mankind. 
3. Shortage of health care workers- All physicians doing a transitional prelim year model- just amazing to see
4. Shortage of CRRT machines- resolving to use of acute PD in certain areas, some using prolonged intermittent renal replacement therapy)
5. QTc monitoring on the screen- so impressed!
6. Fastest trial designs and rapid approvals of treatment is unprecedented for treatment of this deadly virus.
7. Several health startup companies have risen and are trying to use their ways to help combat this virus. See this article in health transformer.

But few things have happened and I have seen it here as well
1. Less red tape with administration- fasted hiring approval I have seen to get someone on board- perhaps we should NOT go back to the old ways
2. Better and more meaningful meetings to get the job done
3. More modesty and acceptance of our strengths and flaws

Perspective: COVID-19: from the Trenches in NY on leadership, clinical care, teaching and research

In the last 3 weeks, our health system has been in the forefront of the entire COVID-19 pandemic in NYC. What I have learnt about leadership, medicine and nephrology is exponential in the last 3 weeks.

As soon as the cases started to rise, our department of medicine chairman started daily calls via Meetings that combined all department chairs, health system experts and division chairs to align the mission at stake. I cannot say how important this call is on setting the stage and the mood as a leader. It is important that all are on the same page and doing this with charisma and ease without panic. I was truly amazed at that. 

In nephrology, we quickly adapted a similar strategy on updated our fellows, faculty, staff on a twice a week basis on similar issues in nephrology.

Some of the issues in Nephrology that the world should consider:

1.       Deploy as many nephrologists in the inpatient setting (your volume will be increasing significantly).  I have not seen volume of AKI at this fold in years in practice.

2.       Re-deploy your fellows/trainees mostly inpatient and few for outpatient dialysis units.

3.       Remember, the other place where you will need help is outpatient dialysis units- beef up your medical directors and get help to them early as they will be 100% occupied- making schedule changes, creating extra shifts for PUIs and extra units/shifts for COVID-19 patients.

4.       Before you deploy to internal medicine help, help might be needed within nephrology itself- as we are in the front line as ESRD docs, inpatient volume increasing and transplant docs as patients with COVID and organ transplants also increase.

5.       Increasing supplies early on and not waiting till you hit peak- ordering more CRRT machines, fluids, cartridges is going to be key.. don’t wait

6.       Back up nursing and making sure you have a good balance between HD and ICU nursing and not stressing both with either HD orders and or CRRT orders.

7.       Anticoagulation might be extremely important in CRRT or citrate protocol( if possible) as clotting is not uncommon in this disease.

8.       Creating a simple but important criteria for need for dialysis in really sick patients and value of RRT in such cases

9.       Implementing and orchestrating (with a division champion) on tele medicine outpatient visits. This can help you fight the COVID fight by keeping your CKD/transplant patients out of the hospital. This is a very critical and important piece.

10.   Making all conferences tele for now but still doing them- education should NOT stop as we are still in the process of teaching along with caring for patients.

11.   Deploying some research strength to learning about COVID in this critical time and sharing information as quickly as possible to the world to allow for ongoing coordinate care.

12.   Separate inpatient and outpatient rounding docs every 2 weeks ( not to mix them) and give the inpatient docs a break.

13.   We also implemented more on call weekend docs for renal help and in addition, added a tele attending on call to help de burden calls on weekends.

14.   Rotation of clerical staff in the office to limit the number of folks in the office ( minimize exposure helps)

15.   Implementing dialysis tele health also helps (but should not replace seeing our ESRD patients). This might be best for our PD and home HD patients.

16.   Can’t stress enough is constant communication—with colleagues, fellows, nurses, staff about any changes. It eases the anxiety and plans for a smoother over a bumpy ride of this long winded ride we are in.

17.   While are in forced implementation of certain tactics due to COVID, perhaps some good tactics should be adopted for long term patient care as we overcome this pandemic. 

18.   The most important part- checking in your nurses, faculty and fellows – creating a group on WhatsApp or any app to share fun pics, old jokes and fun times together as a division. We are all in this together.. Let’s get over this hump…