If there is one certainty during the COVID-19 pandemic, it is that this disease is like no other. The pandemic has overwhelmed intensive care units (ICUs), prompting the need to adjust to ensure the best possible care for critically ill patients while reducing the risk to healthcare workers. Because all of us are learning as we go and hungry for insights from other healthcare professionals and facilities that have been treating patients who are critically ill with COVID-19, SCCM has created the report Configuring ICUs in the COVID-19 Era.
Created with the intention to be continually updated, the report draws on the experiences of critical care physicians, nurses, advanced practice providers, pharmacists, respiratory therapists, biomedical engineers, and environmental staff on the front lines. It reflects insights and improvisations regarding what has worked and lessons learned from a dozen medical centers throughout the country that have been treating significant numbers of COVID-19 patients, from New York City to Omaha, Cincinnati to Atlanta.
Specifically, it addresses rapidly creating and staffing new ICUs; developing new processes of care; rethinking the delivery of respiratory care, pharmacy, and medication management; and instilling new processes to protect staff from aerosolized virus contact.
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The sections include:
Clinical Management Strategy
The report recommends that each hospital develop its own principles and protocols for COVID-19 patient care, starting with appointing a critical care leader who coordinates care via multidisciplinary workgroups that are in continual contact and meet regularly to address issues that continue to evolve, from anticoagulation to equipment management. This approach will help ICUs cut through the red tape to rapidly respond to clinician and patient needs.
Overarching Principles of COVID-19 ICU Management
Minimizing entry into ICU rooms is vital to decrease the risk of exposure to clinicians. The report provides examples of a variety of tasks that can shift from inside to outside the room.
Increasing ICU Capacity
Hospitals that have experienced a surge in COVID-19 patients have had to expand their ICU capacity because of the numbers of patients who need to be treated, as well as the often extended lengths of stay. The report provides suggestions for converting ICUs to COVID-19 ICUs, converting non-ICUs to COVID-19 ICUs, converting operating rooms to COVID-19 ICU rooms, and converting spaces without individual rooms and doors (e.g., postanesthesia care units or cafeterias) into ICUs. When possible, certain activities should be shifted outside the room, but a direct line of sight to the patient is vital, so in some cases this means installing windows in solid doors. This section also addresses the use of a tiered staffing strategy to expand capacity, following guidance described in SCCM’s report United States Resource Availability for COVID-19.
Shifting nursing care farther away from the patient when possible helps reduce staff exposure to the virus. One of the easiest ways to do this is to relocate infusion pumps from the bedside to just outside the room, where nurses can continue to monitor and provide treatment while reducing risk to themselves. The report provides extensive guidance into how this can be achieved based on various configurations and circumstances, while also addressing new issues, such as the need to provide extra boluses to reach the patient and secure tubing so that it is not tripped over.
Physiologic monitoring often drives the need for ICU admission. This section provides guidance regarding how to move the monitor outside the room (as with infusion pumps) or leave it in the room and use a remote control device to prevent repeated access to the room while ensuring that it is visible from outside the room. It also addresses solutions for alarms, such as using baby monitors inside the room that relay information to a receiver outside.
Respiratory care is a central tenet of COVID-19 care and is also the riskiest aspect because of aerosolization of the virus. This section provides extensive guidance for safely providing respiratory care for patients, addressing ventilator circuits and medication management, the use of metered dose inhalers, ventilator alarm management, oxygen supply, noninvasive ventilation, managing medications for nonintubated patients, and respiratory procedures. It also discusses the implementation of prone positioning, which has been shown to be helpful in addressing hypoxemia in COVID-19 patients.
Pharmacy and Medication Management
Pharmaceutical care and coordination of COVID-19 patients is complex. This section provides insights into creating efficient ICU pharmacy operations and managing drug shortages. It also addresses the importance of pharmacy-nurse coordination to minimize exposure risk, including by reducing room entry to administer medications, storing patient-specific medications, decreasing blood sampling for glucose monitoring (diabetes is a significant risk factor for serious illness due to COVID-19), and relocating the pump and medication management.
Beyond moving equipment outside the room, other room environment considerations can reduce risk. This section discusses appropriate donning and doffing zones and protocols, setting up communications between clinicians inside and outside the room, sanitizer dispenser location, and room cleaning and disinfection during and after the patient’s stay. It provides a list of key supplies that reduce risk, such as positioning waste receptacles near the door and ensuring that there are in-room equipment decontamination wipes, as well as practices such as leaving cell phones outside the room and establishing a designated powered air-purifying respirator drying station between cleanings.
Currently, visitors are rarely allowed in hospitals, so it is important to create a solution that helps patients and their loved ones communicate, such as setting up Facetime or Zoom calls every day. Hospitals can enlist social workers, patient representatives, and pastoral care providers to serve as ombudsmen and obtain health information from the clinician and provide it to the patient’s loved ones on a regular basis.
Emotional Support for Staff
Serving on the front lines is overwhelming for clinicians and support staff, who know they are putting themselves at risk while also having fewer support systems to rely on due to social distancing. Hospitals must recognize the mental health challenges to their workers and provide professional psychological and emotional support as well as complementary approaches, such as mindfulness training and therapy animal visits.
Ramping Up Hospital Operations While Maintaining or Ramping Down Expanded ICU Capacity
Now that the curve is flattening, hospitals are resuming standard care, such as elective surgeries, and workers are anxious to return to their former jobs, ICU staff may be at a loss as to how to manage continued care of COVID-19 patients. It is important for administrators to work closely with ICU leaders to develop a transition plan, including reverse engineering of physical alterations that were necessary during the surge. Part of this plan should include addressing an expected second wave of COVID-19 patients during the fall and winter of 2020.
While the pandemic is unprecedented, it is also a harbinger of future outbreaks, and it is vital that ICUs and health systems learn from their shared experiences to successfully address similar challenges if and when they occur. They must gather the lessons learned, take pictures and copious notes, and develop a plan that can readily be activated when needed in the future. In that vein, the living ICU configuration report is intended to be relevant for other large-scale infectious disease crises, which surely will come to our shores again.
The examples of guidance noted in this blog are merely a sample of the rich and insightful information provided in the ICU configuration report.
Download the report today from the SCCM COVID-19 Rapid Response Center.