The COVID-19 pandemic has created enormous demand on the world’s intensive care units. As of today, Central Ohio is still in the very early stages of the outbreak whereas countries such as Italy, Spain, China, and Iran have had large numbers of patients. About 10% of those infected eventually need admission to an intensive care unit so it is the ICUs that get the highest volume of hospitalized patients. When the infection peaks in your community, the hospital has to be prepared for the possibility that the demand for ICU beds could exceed the supply of ICU beds. Here are some of the things to consider in preparation for the peak demand:
Alternate Sites for Intensive Care
The physical characteristics of a hospital room is the first consideration. Not all rooms are as equally adapted to ICU rooms as others. The first consideration is whether there is monitoring capability – those rooms that already have monitors can more easily become ICUs. The second consideration is whether the room has a medical gas supply built into the wall. Many rooms will have oxygen supplies but most ventilators need both oxygen and compressed air supplies in order to blend to a specific oxygen concentration that is delivered to the patient. Wall suction is also necessary. Because COVID-19 patients require droplet isolation, the room should have a door (as opposed to just a curtain).
As you plan for alternative areas for ICU surge care, make up a table of various patient care areas with these various characteristics in mind. Each hospital will be a bit different depending on the availability of monitors, doors, and medical gas supplies in different areas. Some locations may be able to fully meet all specifications for an ICU to care for COVID-19 ICU patients and others may only meet specifications for non-COVID-19 ICU patients. In general, these are the areas that may be considered as ICU expansion areas:
- Existing step-down units
- Cardiac care units
- Other med-surg nursing units
- Surgical pre/post-op recovery rooms
- Endoscopy pre/post-op recovery rooms
- Cardiac cath lab pre/post-op recovery rooms
- Operating rooms
Alternate Nursing and Respiratory Therapy Staff
Just having physical beds does not complete an intensive care unit. You have to also have nurses and respiratory therapists. In times of crisis, many hospital areas will not be active so recruiting operating room nurses, endoscopy nurses, and outpatient clinic nurses should be considered. Not all of these will be adept at caring for critically ill patients with COVID-19 ARDS so alternative staffing models need to be considered: for example, one critical care nurse could be supervising 2-3 recovery room nurses. Respiratory therapists may be more of a limiting factor and may need to be augmented with other health care workers (nurses, NPs, PAs, etc.) who are tangentially familiar with respiratory therapy duties. Also consider identifying nurses and respiratory therapists who have recently retired. EMTs may be another potential resource.
Even if you have enough beds, nurses, and respiratory therapists, if you don’t have ventilators, you cannot treat COVID-19 patients with ARDS. So where do you find ventilators when you run out? There are several possibilities:
- BiPAP machines. These are not ideal but can be adapted to function similarly to a regular ventilator
- Children’s hospitals. COVID-19 primarily affects adults; the older the person, the sicker they tend to get. Children generally do not get as sick. Consequently, there may be extra ventilators at children’s hospitals.
- Home respiratory therapy companies. They may have extra ventilator inventory that could be loaned to the hospital.
- Home ventilator patients. Many of these patients will have a back-up ventilator on hand in case of malfunction of their primary ventilator.
- Gas-powered ventilators. These are often stored in regional disaster caches. The are not a great substitute for a regular ventilator but may be better than rationing ventilators in times of extreme demand.
Alternates to Critical Care Physicians
In some countries, intensive care units are staffed by anesthesiologists but in the United States, ICUs are primarily staffed by critical care physicians. If COVID-19 results in a doubling or tripling of ICU beds, then there will need to be other physicians who can step in. Some of the possibilities include hospitalists, anesthesiologists, emergency medicine physicians, and sleep medicine specialists. Often, it is not necessarily the specific specialty of the physician but instead how old they are. Most internal medicine, surgery, and anesthesiologists do several months of residency training in intensive care units and so those physicians recently out of residency may be more able to stand in for critical care physicians.
The COVID-19 pandemic is not going to last forever but the next 2 months will bring challenges to our nation’s hospitals and particularly our intensive care units. By preparing now and establishing various metrics that would trigger use of these alternate resources, we will be able to match our communities’ COVID-19 needs to the critical care resources of our hospitals.
March 29, 2020