Intensive Care Unit Preparedness During Pandemics and Other Biological Threats

Saliva culture as a predictive indicator for current blood infections and antimicrobial resistance in the ICU setting

Antimicrobial resistance is a worldwide health problem and patients in intensive care are more vulnerable, requiring strict control measures and early identification. Currently, clinical culture materials are used to identify the bacterial agent, but saliva culture is not validated, which has great clinical relevance because it participates in several pathophysiological processes. The aim of this study was to validate saliva culture in an intensive care unit environment, determining its diagnostic value for infection. For this purpose, the results of the 39-month surveillance cultures, from the database of a private hospital were evaluated. A total of 323 cultures were paired between saliva, tracheal secretions, blood and urine from patients who were hospitalized for more than 5 days. The search for correlations between the results was performed using the Spearman correlation test. Severity and evolution data were also correlated. It was possible to correlate the presence of Klebsiella spp. between blood culture and saliva culture in 25% of the results (r = 0.01) and the correlation between saliva and tracheal secretion was 33% (r = 0.33447) with p < 0.0001. In conclusion, saliva can be an excellent discriminator of systemic infections, and can be considered a useful culture in clinical practice.

The Effectiveness of Healthcare System Resilience during the COVID-19 Pandemic: A Case Study

Introduction: The outbreak of the COVID-19 pandemic was a period of uncertainty and stress for healthcare managers due to the lack of knowledge (about the transmission of the virus, etc.) and also due to the lack of uniform organisational and treatment procedures. It was a period where the ability to prepare for a crisis, to adapt to the existing conditions, and to draw conclusions from the situation were of critical importance to keep ICUs (intensive care units) operating. The aim of this project is to compare the pandemic response to COVID-19 in Poland during the first and second waves of the pandemic. This comparison will be used to identify the strengths and weaknesses of the response, including challenges presented to health professionals and health systems and ICUs with COVID-19 patients according to the European Union Resilience Model (2014) and the WHO Resilience Model (2020). The WHO Resilience model was suitable to the COVID-19 situation because it was developed based on this experience. Methods: A matrix of 6 elements and 13 standards assigned to them was created using the EC and WHO resilience guidelines. Results: Good governance in resilient systems ensures access to all resources without constraints, free and transparent flow of information, and a sufficient number of well-motivated human resources. Conclusions: Appropriate preparation, adaptation to the existing situation, and effective management of crisis situations are important elements of ensuring the resilience of ICUs.

Comparing rehabilitation outcomes for patients admitted to the intensive care unit with COVID-19 requiring mechanical ventilation during the first two waves of the pandemic: A service evaluation

OBJECTIVES

To compare rehabilitation outcomes of patients admitted to the intensive care unit with COVID-19 and mechanically ventilated during wave 1 and 2, receiving two different models of physiotherapy delivery.

METHODS

Adults admitted to the intensive care unit between October-March 2021 (wave 2) with a confirmed diagnosis of COVID-19 and mechanically ventilated for >24 hours were included. During wave 2, rehabilitation was provided by physiotherapists over five days, with only emergency respiratory physiotherapy delivered at weekends. Rehabilitation status was measured daily using the Manchester Mobility Score to identify time taken to first mobilise and highest level of mobility achieved at ICU discharge. Outcomes were compared to data previously published from the same ICU during 'wave 1' (March-April 2020) when a seven-day rehabilitation physiotherapy service was provided.

RESULTS

A total of n = 291 patients were included in analysis; 110 from wave 1, and 181 from wave 2. Patient characteristics and medical management were similar between waves. Mean ± SD time to first mobilise was slower in wave 2 (15 ± 11 days vs 14 ± 7 days), with overall mobility scores lower at both ICU (MMS 5 (Step transferring) vs MMS 4 (standing practice) (4), p < 0.05) and hospital (MMS 7 (Mobile > 30 m MMS) vs MMS 6 (Mobile < 30 m MMS), p < 0.0001) discharge. Significantly more patients in wave 2 required ongoing rehabilitation either at home or as an inpatient compared to wave 1 (81 % vs 49 %, p = 0.003).

CONCLUSION

The change in physiotherapy staff provision from a seven-day rehabilitation service during wave 1 to a five day rehabilitation service with emergency respiratory physio only at weekends in wave 2 was associated with delayed time to first mobilise, lower levels of mobility at both intensive care unit and hospital discharge and higher requirement for ongoing rehabilitation at the point of hospital discharge.

Situation Awareness-Oriented Dashboard in ICUs in Support of Resource Management in Time of Pandemics

In a pediatric intensive care unit (PICU) of 32 beds, clinicians manage resources 24 hours a day, 7 days a week, from a large-screen dashboard implemented in 2017. This resource management dashboard efficiently replaces the handwriting information displayed on a whiteboard, offering a synthetic view of the bed's layout and specific information on staff and equipment at bedside. However, in 2020 when COVID-19 hit, the resource management dashboard showed several limitations. Mainly, its visualization offered to the clinicians limited situation awareness (SA) to perceive, understand and predict the impacts on resource management and decision-making of an unusual flow of patients affected by the most severe form of coronavirus. To identify the SA requirements during a pandemic, we conducted goal-oriented interviews with 11 clinicians working in ICUs. The result is the design of an SA-oriented dashboard with 22 key indicators (KIs): 1 on the admission capacity, 15 at bedside and 6 displayed as statistics in the central area. We conducted a usability evaluation of the SA-oriented dashboard compared to the resource management dashboard with 6 clinicians. The results showed five usability improvements of the SA-oriented dashboard and five limitations. Our work contributes to new knowledge on the clinicians' SA requirements to support resource management and decision-making in ICUs in times of pandemics.

Exploring Changes in Patient Safety Incidents During the COVID-19 Pandemic in a Canadian Regional Hospital System: A Retrospective Time Series Analysis

OBJECTIVES

The COVID-19 pandemic has placed unprecedented strain on healthcare systems and may have consequential impacts on patient safety incidents (PSIs). The primary objective of this study was to examine the impact of the COVID-19 pandemic on PSIs reported in Niagara Health.

METHODS

Flexible Farrington models were used to retrospectively detect weeks from January to September 2020 where PSI counts were significantly above expected counts. Incident counts were adjusted to weekly inpatient-days. Outcomes included overall incident numbers, incidents by category, and incidents by ward type.

RESULTS

The overall number of PSIs across Niagara Health did not increase during the first wave of the COVID-19 pandemic. However, significant increases in falls were observed, suggesting that other types of incidents decreased. Falls increased by 75% from February to March 2020, coinciding with the onset of the first wave of the pandemic. Further investigation by unit type revealed that the number of falls increased specifically on internal medicine and complex continuing care wards.

CONCLUSIONS

Despite no observed changes in overall number, significant composition shifts in PSIs occurred during the first wave of the COVID-19 pandemic, with increased falls on internal medicine and complex continuing care wards. Possible explanations include restrictions on patient visitation, reduced patient contact/supervision, and/or personal protective equipment requirements. Providers should maintain a particularly high vigilance for patient falls during pandemic outbreaks, and hospitals should consider targeting resources to higher-risk locations. The results of this study reinforce the need for ongoing pandemic PSI monitoring and rapidly adaptive responses to new patient safety concerns.

Critical care nurses’ perception of moral distress in intensive care during the COVID-19 pandemic – A pilot study

Objectives

To describe critical care nurses’ perception of moral distress during the second year of the COVID-19 pandemic.

Design/Methods

A cross-sectional study involving a questionnaire was conducted. Participants responded to the Italian version of the Moral Distress Scale-Revised, which consists of 14 items divided in dimensions Futile care (three items), Ethical misconduct (five items), Deceptive communication (three items) and Poor teamwork (three items). For each item, participants were also invited to write about their experiences and participants’ intention to leave a position now was measured by a dichotomous question. The data were analysed with descriptive statistics and qualitative content analysis. The study followed the checklist (CHERRIES) for reporting results of internet surveys.

Setting

Critical care nurses (n = 71) working in Swedish adult intensive care units.

Results

Critical care nurses experienced the intensity of moral distress as the highest when no one decided to withdraw ventilator support to a hopelessly ill person (Futile care), and when they had to assist another physician or nurse who provided incompetent care (Poor teamwork). Thirty-nine percent of critical care nurses were considering leaving their current position because of moral distress.

Conclusions

During the COVID-19 pandemic, critical care nurses, due to their education and experience of intensive care nursing, assume tremendous responsibility for critically ill patients. Throughout, communication within the intensive care team seems to have a bearing on the degree of moral distress. Improvements in communication and teamwork are needed to reduce moral distress among critical care nurses.

Intensive care unit staff preparedness as an independent factor for death of patients during COVID-19 pandemic: An observational cohort study

The pandemic of COVID-19 brought to the world an unprecedented challenge. This single center observational study aimed to evaluate the impact of staff preparedness by comparing the outcomes between two intensive care units (ICUs) from a hospital that had to expand ICU beds to deal with an incremented volume of critical patients. Patients consecutively admitted to these ICUs with suspected COVID-19, from March 1st until April 30th, 2020, were included. Both ICUs attended a similar population and had the same facilities, what differed was the staff: one previously well-established (ICU-1) and another recently assembled (ICU-2). 114 patients with severe respiratory syndrome were included. In-hospital mortality was 40%. Compared with patients in the well-established ICU-1, patients in the recently assembled ICU-2 were older (54 versus 61.5, p=0.045), received more antibiotics (93% versus 98%, p=0.001) and chloroquine/hydroxychloroquine 6% versus 30%, p=0.001), had a higher proportion of invasive mechanical ventilation (44% versus 52%, p=0.008) and had greater in-hospital mortality (30% versus 50%, p=0.017). The proportion of patients considered at high risk for death according to PSI was similar between the two ICU populations. Age ≥ 60 years (adjusted OR 2.33; 95% CI 1.02-5.31), need of invasive mechanical ventilation (adjusted OR 2.79; 95% CI 1.22-6.37), and ICU type (recently assembled) (adjusted OR 2.38; 95% CI 1.04-5.44) were independently associated with in-hospital mortality . This finding highlights the importance of developing support strategies to improve preparedness of staff recently assembled to deal with emergencies.

Reduction in perioperative blood loss using ultrasound-activated scissors during tumour surgery

The aim of this study was to compare the effectiveness of Harmonic Focus+ scissors with the conventional surgical method regarding surgical blood loss and transfusion of blood products in the surgical treatment of head and neck tumours. In a retrospective study, the intraoperative blood loss, number of units of transfusion products given, operating time, and inpatient length of stay of 74 patients with squamous cell carcinoma were compared. Patients who underwent classic tumour surgery were compared with a group treated with Harmonic Focus+ scissors. A significantly lower intraoperative blood loss (496.15 ml vs 1096.0 ml, respectively; P = 0.002) and shorter operation time (436.89 minutes vs 493.13 minutes, respectively; P = 0.030) were achieved using the Harmonic Focus+ scissors when compared to the classic tumour surgery. Additionally, fewer units of blood products needed to be transfused (administration of red cell concentrates, P < 0.001) and the length of stay in the intensive care unit was shorter for patients treated with the Harmonic Focus+ scissors (P = 0.009). The study results indicate that the use of Harmonic Focus+ scissors during surgery for cancer of the oral cavity and pharynx is a safe and cost-effective method. This is of paramount importance during a pandemic when medical resources are scarce, including access to blood reserves.

Supervision, Interprofessional Collaboration, and Patient Safety in Intensive Care Units during the COVID-19 Pandemic

Background: To meet coronavirus disease (COVID-19) demands in the spring of 2020, many intensive care (IC) units (ICUs) required help of redeployed personnel working outside their regular scope of practice, causing an expansion and change of staffing ratios. Objective: How did this composite alternative ICU workforce experience supervision, interprofessional collaboration, and quality and safety of care under the unprecedented clinical circumstances at the height of the first pandemic wave as lived experiences uniquely captured during the first peak of the pandemic? Methods: An international, cross-sectional survey was conducted among physicians, nurses, and allied personnel deployed or redeployed to ICUs in Utrecht, New York, and Dublin from April to May of 2020. Data were analyzed separately for the three sites. Quantitative data were treated for descriptive statistics; qualitative data were analyzed thematically and combined for general interpretations. Results: On the basis of 234, 83, and 34 responses (response rates of 68%, 48%, and 41% in Utrecht, New York, and Dublin, respectively), we found that the amount of supervision and the quality and safety of care were perceived as being lower than usual but still acceptable. The working atmosphere was overwhelmingly felt to be collaborative and supportive. Where IC-certified nurse-to-patient ratios had decreased most (Utrecht), nurses voiced criticism about supervision and quality of care. Continuity within the work environment, team composition, and informal ("curbside") consultations were critical mediators of success. Conclusion: In the exceptional circumstances encountered during the COVID-19 pandemic, many ICUs were managed by a composite workforce of IC-certified and redeployed personnel. Although supervision is critical for safe care, supervisory roles were not clearly related to the amount of prior ICU experience. Vital for satisfaction with the quality of care was the span of control for those who assumed supervisory roles (i.e., the ratio of certified to noncertified personnel). Stable teams that matched less experienced personnel with more experienced personnel; a strong, interprofessional, collaborative atmosphere; a robust culture of informal consultation; and judicious, more flexible use of rules and regulations proved to be essential.

Doubling Intensive Care Unit Capacity by Surging Onto Medical-Surgical Units During the COVID-19 Pandemic

INTRODUCTION

The ability of an organization to accommodate a large influx of patients during a prolonged period is dependent on surge capacity. The aim of this article is to describe the surge experience with space, supplies, and staff training in response to COVID-19 and provide guidance to other organizations.

BACKGROUND

A hospital's response to a large-scale event is greatly impacted by the ability to surge and, depending on the type of threat, to maintain a sustained response. To identify surge capacity, an organization must first consider the type of event to appropriately plan resources.

PREPARATION PROCESS

An epidemic surge drill, conducted in 2012, served as a guide in planning for the COVID-19 pandemic. The principles of crisis standards of care and a hospital incident command structure were used to clearly define roles, open lines of communication, and inform our surge plan. Preparation began by collaborating with multidisciplinary groups to acquire the most appropriate space, as well as adequate supplies, and identify and train staff.

IMPLEMENTATION

Teams were formed to identify the necessary resources to expand the intensive care unit (ICU) environment quickly and efficiently. Educational training was developed for redeployed staff.

OUTCOMES

Beth Israel Deaconess Medical Center experienced the largest surge of ICU patients within a hospital system in the state of Massachusetts. The ICU capacity was expanded by 93% from 77 to 149 beds, and the surge was maintained for approximately 9 weeks. Shadowing experiences before the actual surge were extremely valuable.

CONCLUSIONS

Planning for the surge of critically ill patients required a thoughtful, collaborative approach. Ongoing staff support and communication from nursing leadership were necessary to ensure safe, effective care for critically ill patients in a new and dynamic environment.

Main Factors Affecting the Readiness and Responsiveness of Healthcare Systems during Epidemic Crises: A Scoping Review on Cases of SARS, MERS, and COVID-19

Background:

Given the significance of the preparedness and responsiveness of healthcare systems in relation to epidemics, this study aimed to determine their influencing factors during epidemic crises with a view to utilizing the findings in the battle against the coronavirus disease 2019 (COVID-19) outbreak.

Methods:

This scoping study was conducted in 2020 via the Arksey and O’Malley approach. A systematic search was conducted on five online databases from January 2000 to June 15, 2020. Initially, 1926 English articles were retrieved based on their abstracts. After the screening process, 60 articles were considered for the final analysis. Data were charted by applying Microsoft Office Excel 2013 and were synthesized via thematic analysis.

Results:

Five main factors have affected the responsiveness and preparedness of countries during the epidemics of severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19: community-related interventions, managerial interventions, socioeconomic factors, the readiness of hospitals and health centers, and environmental factors. These themes are associated with 38 related sub-themes. The thematic framework shows that interactions between these five determinantes can affect the preparedness and responsiveness of healthcare systems during pandemics/epidemics.

Conclusion:

According to the results, healthcare systems need to pay attention to their internal capacities, managerial interventions, and health centers to overcome the current pandemic. They should also consider such external factors as socioeconomic and environmental determinants that can affect their potential preparedness against pandemic/epidemic crises. Community-related interventions such as improvement of the community health literacy, teamwork, and social responsibility can enhance the readiness of healthcare systems against the COVID-19 outbreak.

Facilitation activities for change response: a qualitative study on infection prevention and control professionals during a pandemic in Brazil

Purpose

Facilitation activities support implementation of evidence-based interventions within healthcare organizations. Few studies have attempted to understand how facilitation activities are performed to promote the uptake of evidence-based interventions in hospitals from resource-poor countries during crises such as pandemics. This paper aims to explore facilitation activities by infection prevention and control (IPC) professionals in 16 hospitals from 9 states in Brazil during the COVID-19 pandemic.

Design/methodology/approach

Primary and secondary data were collected between March and December 2020. Semi-structured interviews were conducted with 21 IPC professionals in Brazilian hospitals during the COVID-19 pandemic. Public and internal documents were used for data triangulation. The data were analyzed through thematic analysis technique.

Findings

Building on the change response theory, this study explores the facilitation activities from the cognitive, behavioral and affective aspects. The facilitation activities are grouped in three overarching dimensions: (1) creating and sustaining legitimacy to continuous and rapid changes, (2) fostering capabilities for continuous changes and (3) accelerating individual commitment.

Practical implications

During crises such as pandemics, facilitation activities by IPC professionals need to embrace all the cognitive, behavioral and affective aspects to stimulate positive attitudes of frontline workers toward continuous and urgent changes.

Originality/value

This study provides unique and timely empirical evidence on the facilitation activities that support the implementation of evidence-based interventions by IPC professionals during crises in hospitals in a resource-poor country.

Caring for critically ill adults in paediatric intensive care units in England during the COVID-19 pandemic: planning, implementation and lessons for the future

OBJECTIVE

To describe the experience of paediatric intensive care units (PICUs) in England that repurposed their units, equipment and staff to care for critically ill adults during the first wave of the COVID-19 pandemic.

DESIGN

Descriptive study.

SETTING

Seven PICUs in England.

MAIN OUTCOME MEASURES

(1) Modelling using historical Paediatric Intensive Care Audit Network data; (2) space, staff, equipment, clinical care, communication and governance considerations during repurposing of PICUs; (3) characteristics, interventions and outcomes of adults cared for in repurposed PICUs.

RESULTS

Seven English PICUs, accounting for 137 beds, repurposed their space, staff and equipment to admit critically ill adults. Neighbouring PICUs increased their bed capacity to maintain overall bed numbers for children, which was informed by historical data modelling (median 280-307 PICU beds were required in England from March to June). A total of 145 adult patients (median age 50-62 years) were cared for in repurposed PICUs (1553 bed-days). The vast majority of patients had COVID-19 (109/145, 75%); the majority required invasive ventilation (91/109, 85%). Nearly, a third of patients (42/145, 29%) underwent a tracheostomy. Renal replacement therapy was provided in 20/145 (14%) patients. Twenty adults died in PICU (14%).

CONCLUSION

In a rapid and unprecedented effort during the first wave of the COVID-19 pandemic, seven PICUs in England were repurposed to care for adult patients. The success of this effort was underpinned by extensive local preparation, close collaboration with adult intensivists and careful national planning to safeguard paediatric critical care capacity.

Derailment or Turning Point? The Effect of the COVID-19 Pandemic on Sustainability-Related Thinking

A pandemic has always been a milestone, forcing intellectuals to reassess the directions of development at their time. This fact has generated vivid debates about the possible reactions to the new situation, highlighting the vulnerability of current socio-economic structures as well as the need to reconsider the current way of development. The new challenge has created an unprecedented increase in academic publications. The aim of the current paper is to analyze the socio-economic aspects of the growing interest in the sustainability-related facets of the pandemic. Based on English language journal articles (n = 1326), collected on the Web of Science website, the authors analyze the different aspects of COVID-related discussions connected to sustainability. Applying the triangulation approach, the publications have been classified on the basis of their intellectual roots, co-occurrence of different words and strategic diagramming. Results highlight that, notwithstanding the remarkable number of papers, there is a strong need for the in-depth analysis of the long-term consequences in the fields of (1) health logistics and policy; (2) the future of education and work, based on experience and evidence; (3) the re-thinking of the resilience of large-scale supply systems; (4) global governance of world affairs, (5) the role of distant teaching, telecommunication, telework, telehealth, teleservices.

Principles of approach to suspected or infected patients related Covid-19 in newborn intensive care unit and pediatric intensive care unit

PURPOSE

In this study, it was aimed to evaluate physical and mental health (MH) effects of children and their parents in newborn intensive care unit and pediatric intensive care unit due to Covid-19.

CONCLUSIONS

Children are less likely to develop severe illness than adults. It may benefit from medical and psychological/behavioral interventions. Prevent negative MH outcomes for babies/children/caregivers affected by Covid-19.

PRACTICE IMPLICATIONS

It is useful to clarify the clinical course of children (treatment, care procedures, psychosocial effects, etc.). The establishment of mental health expert nursing teams, psychological counseling (synchronous telemedicine services for support purposes, telepsychiatry for parents, etc.) may have helped prevent negative mental health of Covid-19 outcomes. Continuous updating of medical staff's knowledge and skills for the prevention of Covid-19 is expected to slow the spread of the disease.

ICU preparedness in pandemics: lessons learned from the coronavirus disease-2019 outbreak

PURPOSE OF REVIEW

The worldwide SARS-CoV-2 pandemic has taken a heavy toll on ICUs worldwide. This review expounds on lessons learned for ICU preparedness during the pandemic and for future mass casualty events.

RECENT FINDINGS

In the 21st century, there have already been several outbreaks of infectious diseases that have led to mass casualties creating ICU strain, providing multiple opportunities for hospitals and hospital systems to prepare their ICUs for future events. Unfortunately, the sheer scale and rapidity of the SARS-CoV-2 pandemic led to overwhelming strain on every aspect of ICU disaster preparedness. Yet, by analyzing experiences of hospitals throughout the first 7 months of the current pandemic in the areas of infection control, equipment preparedness, staffing strategies, ICU spatial logistics as well as acute and postacute treatment, various important lessons have already emerged that will prove critical for successful future ICU preparedness.

SUMMARY

Preemptive planning, beginning with the early identification of staffing resources, supply chains and alternative equipment sources, coupled with strong infection control practices that also provide for the flexibility for evolving evidence is of utmost importance. However, there is no single approach that can be applied to every health system.

SARIMA-modelled greater severity and mortality during the 2010/11 post-pandemic influenza season compared to the 2009 H1N1 pandemic in English hospitals

OBJECTIVE

The COVID-19 pandemic demonstrates the need for understanding pathways to healthcare demand, morbidity, and mortality of pandemic patients. We estimate H1N1 (1) hospitalization rates, (2) severity rates (length of stay, ventilation, pneumonia, and death) of those hospitalized, (3) mortality rates, and (4) time lags between infections and hospitalizations during the pandemic (June 2009 to March 2010) and post-pandemic influenza season (November 2010 to February 2011) in England.

METHODS

Estimates of H1N1 infections from a dynamic transmission model are combined with hospitalizations and severity using time series econometric analyses of administrative patient-level hospital data.

RESULTS

Hospitalization rates were 34% higher and severity rates of those hospitalized were 20%-90% higher in the post-pandemic period than the pandemic. Adults (45-64-years-old) had the highest ventilation and pneumonia hospitalization rates. Hospitalizations did not lag infection during the pandemic for the young (<24-years-old) but lagged by one or more weeks for all ages in the post-pandemic period.

DISCUSSION

The post-pandemic flu season exhibited heightened H1N1 severity, long after the pandemic was declared over. Policymakers should remain vigilant even after pandemics seem to have subsided. Analysis of administrative hospital data and epidemiological modelling estimates can provide valuable insights to inform responses to COVID-19 and future influenza and other disease pandemics.

Assembly Line ICU: what the Long Shops taught us about managing surge capacity for COVID-19

Objectives

To safely expand and adapt the normal workings of a large critical care unit in response to the COVID-19 pandemic.

Methods

In April 2020, UK health systems were challenged to expand critical care capacity rapidly during the first wave of the COVID-19 pandemic so that they could accommodate patients with respiratory and multiple organ failure. Here, we describe the preparation and adaptive responses of a large critical care unit to the oncoming burden of disease. Our changes were similar to the revolution in manufacturing brought about by ‘Long Shops’ of 1853 when Richard Garrett and Sons of Leiston started mass manufacture of traction engines. This innovation broke the whole process into smaller parts and increased productivity. When applied to COVID-19 preparations, an assembly line approach had the advantage that our ICU became easily scalable to manage an influx of additional staff as well as the increase in admissions. Healthcare professionals could be replaced in case of absence and training focused on a smaller number of tasks.

Results

Compared with the equivalent period in 2019, the ICU provided 30.9% more patient days (2599 to 3402), 1845 of which were ventilated days (compared with 694 in 2019, 165.8% increase) while time from first referral to ICU admission reduced from 193.8±123.8 min (±SD) to 110.7±76.75 min (±SD). Throughout, ICU maintained adequate capacity and also accepted patients from neighbouring hospitals. This was done by managing an additional 205 doctors (70% increase), 168 nurses who had previously worked in ICU and another 261 nurses deployed from other parts of the hospital (82% increase).

Our large tertiary hospital ensured a dedicated non-COVID ICU was staffed and equipped to take regional emergency referrals so that those patients requiring specialist surgery and treatment were treated throughout the COVID-19 pandemic.

Conclusions

We report how the challenge of managing a huge influx of patients and redeployed staff was met by deconstructing ICU care into its constituent parts. Although reported from the largest colocated ICU in the UK, we believe that this offers solutions to ICUs of all sizes and may provide a generalisable model for critical care pandemic surge planning.

A California Hospital's Response to COVID-19: From a Ripple to a Tsunami Warning

BACKGROUND

The outbreak of coronavirus disease 2019 (COVID-19) rippled across the world from Wuhan, China, to the shores of the United States within a few months. Hospitals and intensive care units were suddenly faced with a "tsunami" warning requiring instantaneous implementation and escalation of disaster plans.

EVIDENCE REVIEW

An evidence-based question was developed and an extensive review of the literature was completed, resulting in a structured plan for the intensive care units to manage a surge of patients critically ill with COVID-19 in March 2020. Twenty-five sources of evidence focusing on pandemic intensive care unit and COVID-19 management laid the foundation for the team to navigate the crisis.

IMPLEMENTATION

The Critical Care Services task force adopted recommendations from the CHEST consensus statement on surge capacity principles and other sources, which served as the framework for the organized response. The 4 S's became the focus: space, staff, supplies, and systems. Development of algorithms, workflows, and new processes related to treating patients, staffing shortages, and limited supplies. New intensive care unit staffing solutions were adopted.

EVALUATION

Using a framework based on the literature reviewed, the Critical Care Services task force controlled the surge of patients with COVID-19 in March through May 2020. Patients received excellent care, and the mortality rate was 0.008%. The intensive care unit team had the needed respiratory and general supplies but had to continually adapt to shortages of personal protective equipment, cleaning products, and some medications.

SUSTAINABILITY

The intensive care unit pandemic response plan has been established and the team is prepared for the next wave of COVID-19.

Hospitals' responsibility in response to the threat of infectious disease outbreak in the context of the coronavirus disease 2019 (COVID-19) pandemic: Implications for low- and middle-income countries

The WHO declared the coronavirus disease 2019 (COVID-19) outbreak as a public health emergency of international concern on January 30, 2020, and then a pandemic on March 11, 2020. COVID-19 affected over 200 countries and territories worldwide, with 25,541,380 confirmed cases and 852,000 deaths associated with COVID-19 globally, as of September 1, 2020.¹ While facing such a public health emergency, hospitals were on the front line to deliver health care and psychological services. The early detection, diagnosis, reporting, isolation, and clinical management of patients during a public health emergency required the extensive involvement of hospitals in all aspects. The response capacity of hospitals directly determined the outcomes of the prevention and control of an outbreak. The COVID-19 pandemic has affected almost all nations and territories regardless of their development level or geographic location, although suitable risk mitigation measures differ between developing and developed countries. In low- and middle-income countries (LMICs), the consequences of the pandemic could be more complicated because incidence and mortality might be associated more with a fragile health care system and shortage of related resources.2, 3 As evidenced by the situation in Bangladesh, India, Kenya, South Africa, and other LMICs, socioeconomic status (SES) disparity was a major factor in the spread of disease, potentially leading to alarmingly insufficient preparedness and responses in dealing with the COVID-19 pandemic.⁴ Conversely, the pandemic might also bring more unpredictable socioeconomic and long-term impacts in LMICs, and those with lower SES fare worse in these situations. This review aimed to summarize the responsibilities of and measures taken by hospitals in combatting the COVID-19 outbreak. Our findings are hoped to provide experiences, as well as lessons and potential implications for LMICs.

[Intensive care back up for infectious disease disasters]

BACKGROUND

Outbreaks of infectious diseases pose particular challenges for hospitals and intensive care units.

OBJECTIVES

Typical infectiological scenarios and their significance for modern intensive care medicine are presented.

MATERIALS AND METHODS

Selected pathogens/infectious diseases that have significantly strained the resources of intensive care units are described.

RESULTS

Intensive medical care is necessary in severe cases of many infectious diseases. In the context of epidemics/pandemics, many critically ill patients have to be admitted within a short time. Examples are the 2009 H1N1 influenza pandemic, the 2011 enterohemorrhagic Escherichia coli (EHEC) outbreak in northern Germany, the 2014/2015 Ebola fever outbreak and the 2020 coronavirus disease 19 (COVID-19) pandemic. Multidisciplinary teams, protocol development, adequate staffing, and training are required to achieve optimal treatment outcomes, including prevention of healthcare worker infections.

CONCLUSIONS

Pandemics and epidemics are unique challenges for intensive care unit preparedness planning.

Rapid Implementation and Adaptation of a Telehospitalist Service to Coordinate and Optimize Care for COVID-19 Patients

Background/Introduction: The COVID-19 pandemic poses enormous resource challenges to hospitals. Telemedicine is increasingly recognized as an attractive tool to alleviate resource strains. Herein we describe the rapid implementation and sequential process improvement (PI) of a centralized telehospitalist service to coordinate and optimize management of large number of COVID-19 patients in a tertiary and quaternary care hospital very close to the New York City epicenter. Methods: Prospective multidisciplinary PI meetings were held weekly between March 23 and May 10, 2020, and consensus service modifications were implemented for the following week. Inpatient census data, telehospitalist intervention volumes, and service utilization statistics were collected. Results/Discussion: Between March 23 and May 10, 2020, a total of 745 COVID-19 patients were admitted to the general medical wards. The telehospitalist service performed 1,136 audiovisual (AV) patient assessments, 379 best practice interventions, cohorted 108 patients, and conducted 170 remote family conversations. During the consecutive PI cycles, a number of adaptations in AV setup, care standardization, patient logistics, communication, and consultative functions were made to load balance the bedside hospitalist teams. As the COVID-19 hospital census increased to peak levels, the most value was added through facilitation of communication and collaboration between the bedside clinical teams, the infection prevention and control teams, and patient logistics team. Conclusions: A telehospitalist service can be rapidly implemented with basic telemedicine equipment. Processes/this functions can be sequentially adapted to quickly changing needs during conditions such as the COVID-19 pandemic that very quickly can place extraordinary strains on hospital resources.

Care for Critical Ill Patients With COVID-19: Establishment of a Temporary Intensive Care Unit in an Isolated Hospital

The current global spread of COVID-19, a highly contagious disease, has challenged healthcare systems, and placed immense burdens on medical staff globally. With a sharp increase in the number of newly confirmed cases and the rapid progression of the disease into a critically ill state, overstretched critical care units have had to contend with a shortage of beds, specialist personnel, and medical resources. Temporary intensive care units (ICUs) were therefore set up in isolated hospitals to provide the required standardized care for all severe cases. The current paper describes the authors' experience of setting up and managing such an ICU in Wuhan, Hubei Province, China, from the identification of critically ill COVID-19 patients through to the arranging and equipping of the unit, providing training and protection for staff, and standardizing all aspects of care.

Travel/Tropical Medicine and Pandemic Considerations for the Global Surgeon

International travel goes hand in hand with medical delivery to underserved communities. The global health care worker can be exposed to a wide range of infectious diseases during their global experiences. A pretravel risk assessment visit and all appropriate vaccinations and education must be performed. Universal practices of water safety, food safety, and insect avoidance will prevent most travel-related infections and complications. Region-specific vaccinations will further reduce illness risk. An understanding of common travel-related illness signs and symptoms is helpful. Emerging pathogens that can cause a pandemic should be understood to avoid health care worker infection and spread.

Iranian Society of Cardiac Surgeons COVID-19 task force version II, restarting elective surgeries

Given the nature of heart disease and the importance of continuing heart surgery during the pandemic and its aftermath and in order to provide adequate safety for the surgical team and achieve the desired result for patients, as well as the optimal use of ICU beds, the medical team, blood, blood products, and personal protective equipment, it is essential to change the usual approach during the pandemic. There are still a lot of evidences and experiences needed to produce the perfect protocol. Some centers may have a special program for their centers during this period of epidemics that can be respected and performed. Generally, in pandemic conditions, the use of non-surgical approaches is preferred if similar outcomes can be obtained.

The operational readiness capacities of the grassroots health system in responses to epidemics: Implications for COVID-19 control in Vietnam

Background

There is a paucity of data on the operational readiness capacities of the grassroots health system in Vietnam while it plays a vital role as a first-line defense against health emergencies, including the coronavirus disease (COVID-19). This study, therefore, aims to assess the operational readiness capacities of the grassroots health system in response to epidemics and provides implications for controlling COVID-19 in Vietnam.

Methods

An online cross-sectional study using the respondent-driven sampling technique was conducted with 6029 health professionals and medical students in Vietnam from December 2019 to February 2020. The operational readiness capacities of the health system were assessed by the sufficiency of health professionals, administrative and logistics staffs, equipment and facilities, and general capacity of health professionals. Kruskal-Wallis test, Fisher exact test and χ² test were employed to identify the differences among variables. Tobit and censored regression models were operated to determine associated factors.

Results

The operational readiness capacities of the grassroots health system for four assessed criteria were at moderate levels, ranging from 6.3 to 6.8 over 10. In Vietnam, the grassroots health system in rural areas, in the South, and at the district level were more likely to be vulnerable compared to their counterparts.

Conclusions

According to empirical data, this study reveals the vulnerability of the grassroots health system in Vietnam and provides the rationality of prompt and vigorous actions of the Vietnamese Government against COVID-19. Findings also offer useful insights for effective strategies to strengthen the grassroots health system in the long term. In the short term, practicing precautionary measures and mobilizing human resources, as well as medical equipment, are needed to successfully contain COVID-19 in Vietnam.

Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective

In response to the estimated potential impact of coronavirus disease (COVID-19) on New York City hospitals, our institution prepared for an influx of critically ill patients. Multiple areas of surge planning progressed, simultaneously focused on infection control, clinical operational challenges, ICU surge capacity, staffing, ethics, and maintenance of staff wellness. The protocols developed focused on clinical decisions regarding intubation, the use of high-flow oxygen, engagement with infectious disease consultants, and cardiac arrest. Mechanisms to increase bed capacity and increase efficiency in ICUs by outsourcing procedures were implemented. Novel uses of technology to minimize staff exposure to COVID-19 as well as to facilitate family engagement and end-of-life discussions were encouraged. Education and communication remained key in our attempts to standardize care, stay apprised on emerging data, and review seminal literature on respiratory failure. Challenges were encountered and overcome through interdisciplinary collaboration and iterative surge planning as ICU admissions rose. Support was provided for both clinical and nonclinical staff affected by the profound impact COVID-19 had on our city. We describe in granular detail the procedures and processes that were developed during a 1-month period while surge planning was ongoing and the need for ICU capacity rose exponentially. The approaches described here provide a potential roadmap for centers that must rapidly adapt to the tremendous challenge posed by this and potential future pandemics.

Preparing your intensive care unit for the COVID-19 pandemic: practical considerations and strategies

The coronavirus disease 2019 (COVID-19) has rapidly evolved into a worldwide pandemic. Preparing intensive care units (ICU) is an integral part of any pandemic response. In this review, we discuss the key principles and strategies for ICU preparedness. We also describe our initial outbreak measures and share some of the challenges faced. To achieve sustainable ICU services, we propose the need to 1) prepare and implement rapid identification and isolation protocols, and a surge in ICU bed capacity; (2) provide a sustainable workforce with a focus on infection control; (3) ensure adequate supplies to equip ICUs and protect healthcare workers; and (4) maintain quality clinical management, as well as effective communication.

Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy

The first person-to-person transmission of the 2019 novel coronavirus in Italy on 21 February 2020 led to an infection chain that represents one of the largest known COVID-19 outbreaks outside Asia. In northern Italy in particular, we rapidly experienced a critical care crisis due to a shortage of intensive care beds, as we expected according to data reported in China. Based on our experience of managing this surge, we produced this review to support other healthcare services in preparedness and training of hospitals during the current coronavirus outbreak. We had a dedicated task force that identified a response plan, which included: (1) establishment of dedicated, cohorted intensive care units for COVID-19-positive patients; (2) design of appropriate procedures for pre-triage, diagnosis and isolation of suspected and confirmed cases; and (3) training of all staff to work in the dedicated intensive care unit, in personal protective equipment usage and patient management. Hospital multidisciplinary and departmental collaboration was needed to work on all principles of surge capacity, including: space definition; supplies provision; staff recruitment; and ad hoc training. Dedicated protocols were applied where full isolation of spaces, staff and patients was implemented. Opening the unit and the whole hospital emergency process required the multidisciplinary, multi-level involvement of healthcare providers and hospital managers all working towards a common goal: patient care and hospital safety. Hospitals should be prepared to face severe disruptions to their routine and it is very likely that protocols and procedures might require re-discussion and updating on a daily basis.