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A Dedicated "COBRA" Team Provides Bundled Vascular and Enteral Access in Critically Ill COVID-19 Patients

Key findings

  • In early April 2020, Massachusetts General Hospital created a multidisciplinary team to provide bundled vascular and enteral access in critically ill COVID-19 patients
  • At daytime, the team included four surgical residents and a dedicated attending (surgeon, anesthesiologist or interventional radiologist); overnight, two surgical residents worked with the on-call trauma surgeon
  • Over the two-week interim study period, the team effectively met procedural demands, mostly arterial lines (55%), central venous catheters (25%) and non-tunneled hemodialysis catheters (13%), and there were no major complications of these procedures
  • Challenges included high patient body mass index, access needs during prone positioning and arterial catheter–associated thrombosis

During the first few weeks that the COVID-19 pandemic affected Massachusetts General Hospital, the number of mechanically ventilated ICU patients rose exponentially. According to plan, several medical and surgical floors were converted into surge ICUs, but the pool of available intensivists, residents and advanced practice providers was quickly spread thin.

To address the constraints on personnel and resources, a dedicated team was created to provide bundled vascular and enteral access in critically ill COVID-19 patients. In Annals of Surgery, Katherine Albutt, MD, MPH, surgical resident, Casey Luckhurst, MD, surgical resident, and Haytham Kaafarani, MD, MPH, trauma surgeon, and director of the Mass General Center for Outcomes & Patient Safety in Surgery (COMPASS) at Massachusetts General Hospital, and colleagues describe the team's structure and initial experience.


The COVID-19 Bundled Response for Access (COBRA) team was created within 72 hours in early April 2020 by representatives of the Departments of Surgery; Anesthesia, Critical Care and Pain MedicineInterventional Radiology; Medicine; and Nursing and Patient Care Services. The Hospital Incident Command System approved the plan and feedback was solicited from ICU leaders.

Procedures and Structure

The bundled procedures performed by the COBRA team included arterial lines, central venous catheters (CVC), non-tunneled hemodialysis (HD) catheters and orogastric/nasogastric tubes.

During the day, four surgical residents (postgraduate years 3–7) worked two per team along with a dedicated attending (surgeon, anesthesiologist or interventional radiologist). Overnight, two surgical residents worked with the on-call trauma surgeon. Participation in COBRA at all levels was strictly voluntary.


For the convenience of ICU teams, a dedicated COBRA pager was created with an easy search-and-find feature in the hospital telephone directory. The initial plan was for the team to operate only from 6 am to 6 pm, but demand was so high in the first 24 hours that coverage was expanded to be around the clock.


Components of COBRA were chosen to promote safe, efficient care and participant safety. They included:

  • An in-depth checklist to facilitate communication between ICU teams and the COBRA team
  • A checklist to guide COBRA team members through pre-procedural, procedural and post-procedural steps
  • Procedure "go bags" with all essentials for catheter placement
  • A dedicated space to house necessary materials, including ultrasound machines
  • Full personal protective equipment (strict contact and airborne precautions with N95 respirator)
  • Mandatory online and in-person PPE training, including N95 fit testing, supplemented with training about donning and doffing PPE in a sterile environment

Volume and Outcomes

The COBRA team was enthusiastically received across the hospital and effectively met procedural demands. Over a two-week interim study period, it responded to 158 consults on 102 patients and performed 214 procedures, mostly arterial lines (55%), CVC (25%) and HD catheters (13%). During the study period, there were no complications with these procedures.


  • The average patient body mass index was 32 kg/m2, which presented challenges with patient positioning and procedural techniques
  • Many patients had access needs during prone positioning
  • The most frequent challenge was arterial catheter–associated thrombosis requiring rewiring or replacement of the catheter

Team members attempted to reduce the risk of future thrombosis by minimizing vascular access attempts prior to COBRA consultation, using ultrasound guidance for arterial line placement and using longer arterial catheters to minimize accidental dislodgement.

The COBRA team hopes that by sharing its experience, other hospitals can better prepare for COVID-19 surges and other disaster needs.

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