Patient Care in Rapid-expansion Intensive Care Units During the COVID-19 Pandemic Crisis

Jade I. Basem; Anna F. Roth; Robert S. White; Virginia E. Tangel; Silis Y. Jiang; Jacky M. Choi; Katherine L. Hoffman; Edward J. Schenck; Zachary A. Turnbull; Kane O. Pryor; Natalia S. Ivascu; Stavros G. Memtsoudis; Peter A. Goldstein

Disclosures

BMC Anesthesiol. 2022;22(209) 

In This Article

Background

The Coronavirus-19 (COVID-19) pandemic, resulting from the coronavirus SARS-CoV-2, was first reported to have arrived in New York City (NYC) on March 1, 2020;[1] the first reported NYC death occurred on March 14.[2] As of 31 August 2021, the number of confirmed cases in NYC was 847,342, with 119,450 hospitalizations, and 28,664 confirmed deaths (https://www1.nyc.gov/site/doh/covid/covid-19-data.page).

Reports from China[3] and Europe[4] indicated wide clinical symptomatology—individuals could be asymptomatic carriers, mildly ill, to presenting with acute respiratory distress syndrome (ARDS). The high-degree of infectivity associated with COVID-19 (and the widespread presence of asymptomatic carriers)[5] likely contributed to the exponential growth seen during the pandemic's early stages.[6,7] The rapid increase in critically ill patients overwhelmed many hospitals and the United States, unfortunately, did not have critical care resources available to manage a crisis of this magnitude.[8,9] With emergence of the highly transmissible Delta (B.1.617.2) variant of SARS-CoV-2,[10] global regions relatively spared from the first wave of infection in 2020 (e.g., Australasia) now face increasing stress on critical care resources[11,12] due to the high rate of hospitalization associated with this variant.[13,14]

Anticipating a surge of critically ill COVID-19 patients, our hospital convened a multidisciplinary working group with representation from senior hospital administration, chiefs of service, nursing administration, and facilities management and engineering to consider how to efficiently increase our intensive care unit (ICU) capacity.[15,16] Prior to the onset of the pandemic, there were a total of 109 adult intensive care unit (ICU) beds at NewYork-Presbyterian/Weill Cornell Medical Center (NYP-WCMC) distributed across a number of different care units: Burn (n = 15), Cardiac (n = 20), Cardiothoracic (n = 20), Medical (n = 20), Neurosurgical (n = 14), and Surgical/Post-Anaesthesia (n = 20).

It was determined that operating rooms (ORs) and post-anaesthesia care units (PACUs) were the most feasible locations for initial expansion (herein referred to as 'Expansion-ICUs') because of the available pre-existing infrastructure and personnel familiar with the majority of procedures commonly performed in critical care settings. At the peak of the pandemic, 60 Expansion-ICU beds were operational. During this time, all patients admitted to the traditional ICU and Expansion-ICU were intubated requiring mechanical ventilation.

During NYC's COVID-19 spring 2020 surge, essentially all patients who were eligible for ICU care were intubated, thus, intubation was the prerequisite for our ICU referent cohort. Justification for the development of the Expansion-ICUs in the operating room was multifactorial and included limited number of traditional ICU ventilators (thus necessitating the use of anaesthesia machines as ventilators), the possible need to use a single ventilator for more than one patient ("split-ventilator" strategy), and limited number of critical care staff (physicians and nurses). Staffing these additional beds was accomplished with physicians (attending faculty, residents) from the Departments of Anesthesiology and Surgery, and perioperative nursing staff, including operating room and postoperative care nurses, with respiratory/ventilator support provided by Certified Registered Nurse Anaesthetists (CRNAs).[15,16] Staff were redeployed based on request and volunteerism to work in COVID ICU's with schedules released two weeks at a time.[15]

To provide data-based support for the rapid development and deployment of critical care resources during an evolving global pandemic, we performed a retrospective chart review of care characteristics between patients in the standard and non-standard Expansion-ICU setting during the initial phase of COVID-19 crisis at an academic medical center in NYC.

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