COVID-19 CLINICAL ROUNDS

COVID-19 CLINICAL ROUNDS

MASS CRITICAL CARE SERIES

Tanzib Hossain, MD, MS

NYU Langone Health

Vikram Mukherjee, MD

Bellevue Hospital Center

Amit Uppal, MD

Bellevue Hospital Center

Doug Ornoff, MD, PhD

SCL Health Network, Denver

System Level Surge Capacity: Crucial Strategies

January 26, 2021

COVID-19 CLINICAL ROUNDS

MASS CRITICAL CARE SERIES

System Level Surge Capacity: Crucial Strategies

January 26, 2021

Staffing and Resilience StrategiesFebruary 2, 2021

Communication and Coordination StrategiesFebruary 9, 2021

Background

3

• December 10, 2020 Project ECHO

presentation discussed

• Crisis standards of care

– Substantial change in usual health care

operations created by a catastrophic

disaster, such as a pandemic, impairing

delivery of care

• Task Force for Mass Critical Care

– Interdisciplinary and international group of

disaster professionals dedicated to defining

disaster standards for best care

– Contributed to a 2014 consensus statement

and a 2019 textbook on ICU management in

disasters

• Current Task Force project introduced

Task Force for Mass Critical Care Current Project

4

• Objective

– Develop system-level suggestions for confronting the overwhelming COVID-19 surge

• Goals of System-level Surge Management

– Maintain standard of care for every patient within the system for as long as possible in the face of a

surge

– Ensuring that the burden on health care professionals is alleviated while safeguarding system

sustainability

John L. Hick, Sharon Einav, Dan Hanfling, Niranjan Kissoon,

Jeffrey R. Dichter, Asha V. Devereaux, Michael D. Christian.

“Surge Capacity Principles: Care of the Critically Ill and Injured

During Pandemics and Disasters: CHEST Consensus

Statement”. Chest 2014 Volume 146, Issue 4. Pages e1S-e16S.

https://doi.org/10.1378/chest.14-0733


5

• Objective

– Develop system-level suggestions for confronting the overwhelming COVID-19 surge

• Goals of System-level Surge Management

– Maintain standard of care for every patient within the system for as long as possible in the face of a

surge

– Ensuring that the burden on health care professionals is alleviated while safeguarding system

sustainability

• Three major project groups:

– Surge capacity: strategies to manage surge at the hospital and health system level, with focus on ICU

beds, ventilators, and supplies

– Staffing strategies, shortages, and resiliency: February 2

– Communication and coordination strategies for movement of patients across health systems,

regions, and states: February 9


6

Disseminate findings in real time through various

written and virtual formats to aide personnel from large

hospitals, health systems, and healthcare coalitions in

engaging with Mass Critical Care experts for a

dynamic exchange of information and experiences.

Brainstorm novel solutions to address system-level

demands of the pandemic and crisis levels of care

Surge Suggestions - Space

7

• Challenge

– Inadequate negative pressure spaces for management of surge in patients with COVID-19

• Literature

– To create primary ICU space for the surge of patients with COVID-19, many ICU beds in single rooms with windows were retrofitted using high-efficiency particulate air (HEPA) filtration devices vented externally to create a negative airflow. Special care was given to the location of the vented air and its proximity to other hospital systems. Achieving independent isolationrooms allowed staff to work freely in the area, donning PPE only when entering patients’ rooms

• Experience

Negative Airflow Rooms

with HEPA Filters

Negative Pressure Spaces Constructed

Using Temporary Barriers

Surge Suggestions - Supplies

8

• Challenge

– Inadequate supply of critical care equipment to match needs of critically ill patients with COVID-19

• Literature

– The network supply of ICU ventilators was supplemented with ventilators from federal stockpiles, as well as from product vendors. Ventilators not specifically designed for ICU use were also obtained. We developed a system to use these for patients who had stabilized and could be stepped-down to a non-ICU ventilator

• Experience

Surge Suggestions - Supplies

9

• Challenge

– Inadequate supply of critical care equipment to match DIALYSIS needs of critically ill patients with COVID-19 in renal failure after prolonged hospitalization

• Literature

– N/A

• Experience

Peritoneal Dialysis Initiated in the ICU

Tablo Home Dialysis Machines

Brought into the ICU

THANK YOU

System-Level Surge Capacity References

11

1. Arabi YM, Murthy S, Webb S. COVID-19: a novel coronavirus and a novel challenge for critical care. Intensive Care Med. 2020;46(5):833-836.

2. Aziz S, Arabi YM, Alhazzani W, et al. Managing ICU surge during the COVID-19 crisis: rapid guidelines. Intensive Care Med. 2020;46(7):1303-1325.

3. Bader MK, Braun A, Fox C, et al. A California Hospital's Response to COVID-19: From a Ripple to a Tsunami Warning. Crit Care Nurse. 2020:e1-e16.

4. Borgen I, Romney MC, Redwood N, et al. From Hospital to Home: An Intensive Transitional Care Management Intervention for Patients with COVID-19. Popul Health Manag. 2020.

5. Carenzo L, Costantini E, Greco M, et al. Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy. Anaesthesia. 2020;75(7):928-934.

6. Coughlan C, Nafde C, Khodatars S, et al. COVID-19: lessons for junior doctors redeployed to critical care. Postgrad Med J. 2020.

7. Craxi L, Vergano M, Savulescu J, Wilkinson D. Rationing in a Pandemic: Lessons from Italy. Asian Bioeth Rev. 2020:1-6.

8. Deep A, Knight P, Kernie SG, et al. A Hybrid Model of Pediatric and Adult Critical Care During the Coronavirus Disease 2019 Surge: The Experience of Two Tertiary Hospitals in London and

New York. Pediatr Crit Care Med. 2020.

9. DiSilvio B, Virani A, Patel S, et al. Institutional COVID-19 Protocols: Focused on Preparation, Safety, and Care Consolidation. Crit Care Nurs Q. 2020;43(4):413-427.

10. Donker T, Burkin F, Wolkewitz M, et al. Navigating hospitals safely through the COVID-19 epidemic tide: predicting case load for adjusting bed capacity. Infect Control Hosp Epidemiol.

2020:1-14.

11. Faccincani R, Pascucci F, Lennquist S. How to Surge to Face the SARS-CoV-2 Outbreak: Lessons Learned From Lombardy, Italy. Disaster Med Public Health Prep. 2020:1-3.

12. Goh KJ, Wong J, Tien JC, et al. Preparing your intensive care unit for the COVID-19 pandemic: practical considerations and strategies. Crit Care. 2020;24(1):215.

13. Griffin KM, Karas MG, Ivascu NS, Lief L. Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective. Am J Respir Crit Care Med. 2020;201(11):1337-1344.

14. Harris GH, Baldisseri MR, Reynolds BR, Orsino AS, Sackrowitz R, Bishop JM. Design for Implementation of a System-Level ICU Pandemic Surge Staffing Plan. Crit Care Explor.

2020;2(6):e0136.

15. Harvey S, Zalud I. Obstetric hospital preparedness for a pandemic: an obstetric critical care perspective in response to COVID-19. J Perinat Med. 2020;48(9):874-882.

16. Joyce CL, Howell JD, Toal M, et al. Critical Care for Coronavirus Disease 2019: Perspectives From the PICU to the Medical ICU. Crit Care Med. 2020;48(11):1553-1555.

17. Kashyap S, Gombar S, Yadlowsky S, et al. Measure what matters: Counts of hospitalized patients are a better metric for health system capacity planning for a reopening. J Am Med Inform

Assoc. 2020;27(7):1026-1131.

18. Litton E, Bucci T, Chavan S, et al. Surge capacity of intensive care units in case of acute increase in demand caused by COVID-19 in Australia. Med J Aust. 2020;212(10):463-467.

19. Michelson KA, Rees CA, Sarathy J, et al. Inter-Region Transfers for Pandemic Surges. Clin Infect Dis. 2020.

20. Nunez-Villaveiran T, Gonzalez-Castro A, Nevado-Losada E, Garcia-de-Lorenzo A, Garro P. All for One and One for All: Voluntary Physicians in the Intensive Medicine Units during the Covid-

19 Outbreak in Spain. Disaster Med Public Health Prep. 2020:1-21.

21. Remy KE, Verhoef PA, Malone JR, et al. Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists. Pediatr Crit Care Med.

2020;21(7):607-619.

22. Singh J, Green MB, Lindblom S, Reif MS, Thakkar NP, Papali A. Telecritical Care Clinical and Operational Strategies in Response to COVID-19. Telemed J E Health. 2020.

23. Uppal A, Silvestri DM, Siegler M, et al. Critical Care And Emergency Department Response At The Epicenter Of The COVID-19 Pandemic. Health Aff (Millwood). 2020;39(8):1443-1449.

24. Weissman GE, Crane-Droesch A, Chivers C, et al. Locally Informed Simulation to Predict Hospital Capacity Needs During the COVID-19 Pandemic. Ann Intern Med. 2020;173(1):21-28.

25. Wood RM, McWilliams CJ, Thomas MJ, Bourdeaux CP, Vasilakis C. COVID-19 scenario modelling for the mitigation of capacity-dependent deaths in intensive care. Health Care Manag Sci.

2020;23(3):315-324.

26. Wurmb T, Scholtes K, Kolibay F, et al. Hospital preparedness for mass critical care during SARS-CoV-2 pandemic. Crit Care. 2020;24(1):386.

System-Level Surge Capacity Literature Search

12

• Search Terms

– Surge capacity

– Intensive Care Unit

– ICU

• Search Timeline

– January to

December 2020

(to focus on

COVID-19)Pediatrics

12 additional

articles

1 society

statement

13

East West

Non Covid ICU 5400

Non Covid Acute Medicine Epilepsy

Procedural Area 5300

Covid ICU Pediatrics

Covid Acute Nursery NICU

Unit Staff Reassigned

Endoscopy

Cystoscopy

Augustana

4800 4900

Surgery Medicine

Radiology

PACU 1

5

5500 5600 5700 5800 5900

Medicine Medicine Medicine Med Stepdown Psychiatry

5100

5200 Mother Baby Labor & Delivery

4 4

PACU 2

4300

MICU

PACU 3

3 33500 3600

Cath/IRRehab Neurology

2

2 Emergency Department FHC Clinics Chapel/Coffee Shop/Offices

1 COVID Testing Center

OR

4600Mixed ICU

4500Intermediate/Med/Surg

Non Covid ICU East West

Non Covid Acute

Procedural Area

Covid ICU

Covid Acute

Unit Staff Reassigned Nursery NICU

4500

MICU (24)

Endoscopy

Cystoscopy

3600

Neuro

Station 14

Vaccine Center

FHC Clinics

Station 12

ED non-COVID

Augustana

5100

Med Iso (36) Med Iso (41)

4800 4900

5

5400 5500 5600/5700 5800 5900

Med Iso(2)/ Drop (21) Med Drop (30) Med Drop (30) MICU (16) Psychiatry

5200/5300 Med Drop(48) Labor & Delivery

4 4

4500 4600

4300

MICU/SICU

P3 MICU (8)

Med Iso (25) MICU (14)

P2 MICU (6)

PACU 1

3Augustana 3

33500 3600

Cath/IR RadiologyMed Iso (40) Med Drop(18)/Iso(12) MICU (12)

Chapel/Coffee Shop/Offices

2Augustana 2

2 Emergency Department

Mother/Baby/Peds

1 ED Surge/COVID Testing

OR

4

80

Organizational Surge Plan

To Increase ICU Space

System-Level Surge Capacity Literature Suggestions

14

• Organizational

– For a comprehensive management of a pandemic and mass critical care, hospitals have to switch from the conventional mode of leadership to crisis mode with appropriate hospital incident command structures (Wurmb)

– Key to managing a pandemic is preplanning, and intensive care unit practitioners are identified as key contributors to planning for and managing pandemics, especially the COVID-19 outbreak (Bader)

– Proactively addressing key pandemic strategies before the next surge or disaster will assist ICU teams to mitigate threats, build processes to manage the crisis, and optimize patient outcomes (Bader)

– Every institution must develop a surge plan unique to their facility, which is based on availability and skill level of staff, accessibility to resources, hospital layout, bed capacity, and anticipated community need (DiSilvio)

– We recommend that healthcare institutions and ICUs develop and implement response plans to clinical emergencies such as endotracheal intubation and cardiac arrest for patients with COVID-19 (Aziz) because managing cardiac or respiratory arrest require specific alterations in bagging and compressions due to the increased risk of aerosol generation with COVID-19 (Bader)

– Many usual hospital functions may need to be suspended during the acute surge of patients with COVID-19, including parts of ambulatory care and elective surgeries, to liberate staff for redeployment (Uppal)

– In the event of a mass influx of critically ill patients defined as “Mass Critical Care”, the primary goal must be to maintain the response category “conventional care” or at least “contingency care” for as long as possible…“Crisis care” based on disaster medicine principles must be avoided at all costs or delayed as long as possible by appropriate measures (Wurmb)


15

• Space

– Hospitals should always have plans to augment ICU bed capacity, which may include doubling single rooms and transforming operating rooms, post-anesthesia care units, step-down units, endoscopy areas, and general wards into ICUs (Arabi, Bader, Weissman)

– It may be necessary to expand ward care into unused clinical spaces (for example, newly built but not yet opened hospital floors or previously closed wings of long-term acute care hospitals), ward like care spaces (dialysis and apheresis units), and into non-care spaces (such as building lobbies) (Weissman)

– To create primary ICU space for the surge of patients with COVID-19, many ICU beds in single rooms with windows were retrofitted using high-efficiency particulate air (HEPA) filtration devices vented externally to create a negative airflow. Special care was given to the location of the vented air and its proximity to other hospital systems. Achieving independent isolationrooms allowed staff to work freely in the area, donning PPE only when entering patients’ rooms (Uppal)

– When planning for increased mechanical ventilation capacity, requirements of oxygen/medical gas supply, electrical supply, airway management and ventilation consumables, physical space, and staff necessary to effectively and safely deliver mechanical ventilation must be considered (Aziz)


16

• Supplies

– Supplies and equipment were critical to managing an ICU surge during the pandemic, with essential supplies including respiratory equipment, pharmaceuticals, personal protective equipment, intravenous fluid pumps, and monitors (Bader)

– Pharmacological protocols were either created or updated to include alternative medications used during the pandemic. Physicians were encouraged to order alternatives to propofol and midazolam because these medications reached critical shortages. Expansion of sedation agents included using lorazepam or ketamine as alternatives. When the shortage of fentanyl reached critical levels, physicians were asked to change analgesics to others in more abundant supply, such as hydromorphone or morphine sulfate (Bader)

– To help keep supplies in code and intubation carts clearn, “COVID-19 ACLS kits” and “COVID-19 RSI kits” housed in disposable, plastic bags sitting atop the crash cart permit the entire kit to be taken into a COVID-19 patient's room during a code or intubation (DiSilvio)

– The network supply of ICU ventilators was supplemented with ventilators from federal stockpiles, as well as from product vendors. Ventilators not specifically designed for ICU use were also obtained. We developed a system to use these for patients who had stabilized and could be stepped-down to a non-ICU ventilator (Uppal)

System-Level Surge Capacity: Space Considerations

17

Negative Airflow Rooms

with HEPA FiltersNegative Pressure Spaces Constructed

Using Temporary Barriers Low Oxygen Pressure Alarm

COVID-19 CLINICAL ROUNDS

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