|Ahead of print publication
Planning a modular intensive care unit for patients of the COVID-19 pandemic
Shankar Narayan1, Rangraj Setlur2, Nikahat Jahan3, Kaushik Chatterjee4, Madhuri Kanitkar5
1 Commanding Officer, INHS Kalyani, Visakhapatnam, India
2 Professor & Head, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, India
3 Associate Professor, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, India
4 Professor & Head, Department of Psychiatry, Armed Forces Medical College, Pune, India
5 Deputy Chief of Integrated Defence Staff (Medical), Integrated Defence Headquarters, New Delhi, India
|Date of Submission||14-Jul-2020|
|Date of Decision||16-Aug-2020|
|Date of Acceptance||21-Aug-2020|
|Date of Web Publication||14-Sep-2020|
Department of Anesthesiology and Critical Care, AFMC, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: The COVID-19 pandemic has provided opportunity to the Armed Forces Medical Services (AFMS) healthcare institutions to plan and execute their surge capacity facilities and identify areas for improvements in planning in the future. Material and Methods: Available medical literature on the experiences of other countries in activating surge capacities in healthcare for the pandemic were examined in detail as were existing guidelines for establishing Intensive Care Units (ICU). Personal communications with peers to understand difficulties faced in activating surge capacities were also factored in. Results: Based on the findings from these sources, a plan to establish ten-bedded ICU units specifically for COVID-19 is evolved. The best practices and latest guidelines and experiences have been collated and modified suitably to suit the AFMS in this aspect. Conclusion: Planning ICUs in ten-bedded modular units will enable the AFMS to cater to surge capacities in the future for all situations where sudden increase in number of patients is anticipated.
Keywords: Intensive Care Unit, COVID-19, surge capacity
| Introduction|| |
With the COVID-19 pandemic affecting our country, various steps have been implemented by the administration to slow down transmission of the virus. This gives existing health-care organisations time to quickly plan and activate their surge capacities to be ready to cater to a large number of patients over a short period of time, when it is finally required.
While there exists literature on the norms for the establishment of intensive care units (ICUs) for normal patient-load, there are no specific studies or recommendations for creating such ICUs during a pandemic, when the number of patients is likely to be very high with large numbers needing intensive care rising within a short span of time. Against this background, this article examines the existing literature, norms, experience gained and also makes recommendations for planning of an ICU with the treatment of COVID-19 patients in focus.
| Materials and Methods|| |
An electronic search of medical literature available on the internet was conducted to identify recent articles on the nature of COVID-19 as well as the kind of care required. Medical literature on experiences and plans of other countries in catering to anticipated surge in the need for ICU beds were also studied. Indian guidelines for intensive care facilities were taken into account. Experience of peers in creating extra ICU facilities during previous natural disasters (personal communications) were also considered to arrive at the findings.
| Results|| |
Number of beds
The recommended number of beds in a normal ICU is between 8 and 12 and this agrees with data from other countries as well. For example, in Lombardy in Italy, 74 hospitals had 720 ICU beds (about 10 beds per hospital) and in Australia, 2261 ICU beds in 178 hospitals, averaging 12 beds per ICU., Keeping in mind the strict infection control measures and donning of personal protective equipment (PPEs) in a COVID-19 ICU, we propose a 10-bed ICU module. A 10-bed ICU is an ideal structural and functional unit. The requirement of additional ICU beds in larger hospitals can be catered for in multiples of 10-bedded units, to keep staff and material movements efficient and reduce risk of infection in health workers. For example, a tertiary care referral hospital could have two or three modules of the 10-bed ICU and a district hospital could have one or two modules depending on the anticipated case load.
Equipment for each intensive care unit bed
Based on the initial Chinese experience, it was estimated that about 5% of all patients would need ICU admissions. However, the Italian experience showed that 16% of all admitted COVID-19 patients needed ICU care. Since almost all patients requiring ICU care would need ventilation, an advanced ICU ventilator would be needed for each bed.
Along with the ventilator, each bed would need various other equipment needed for monitoring, clinical examination as well as providing other aspects of intensive care, including therapy. The list of equipment required per bed is shown in [Table 1].
Shared equipment for intensive care unit
Equipment needed for the ICU unit as a whole is depicted in [Table 2]. When more than one 10-bedded COVID-19 ICU is required to be set up, it would be best that each such ICU is self-contained in terms of these equipment to avoid chances of infection due to frequent movements of samples and personnel.
Staff requirements for COVID intensive care unit of 10 beds
There is a need to balance the shortage of available staff with the high standards of critical care and infection control that need to be maintained at all times when dealing with COVID-19 patients. This is more relevant in an ICU setting where multiple procedures generating aerosols are commonly performed. Adequate staff is needed to cater to enhanced clinical and infection control demands. Allowance also has to be made for the limitations that are inherent to working in full PPEs.,
The staff will need to work in shifts to prevent fatigue, reduce breaches in infection control practices and eliminate errors while maintaining high standards of intensive care.,
Based on all these factors, the suggested workforce, working in shifts, in a 10-bedded COVID ICU is shown in [Table 3]. Modifications will need to be made for each institution taking into account the available human resources.
Other medical requirements
One of the most important aspects of setting up a COVID ICU is the Medical Gas pipeline. This should provide for 2 oxygen, 1 compressed air and 1 suction port at every bed. Setting up a new pipeline takes about 5–7 days only. An emergency backup for the oxygen pipeline should always be included in the initial plan itself and the staff working in the ICU must be aware of how to activate the emergency oxygen pipeline if the main supply fails for any reason. At least one noiseless suction should be available between every two ICU beds, as a backup for failure of central suction.
The hospital should have laboratory and imaging services to support the ICU. Facilities for diagnostic testing for COVID-19, though preferable in-house, can be outsourced if not available within the hospital.
Requirement of PPE for the staff working in the ICU has been worked out and is shown in [Table 4].
Infrastructure requirements for COVID intensive care unit
Ideally, the COVID ICU should have individual rooms for patient isolation with negative pressure rooms and stand-alone air-conditioning. The COVID ICU requires a separate heating, ventilation and air conditioning (HVAC) system, which is not shared with any other area of the hospital. This is required to limit the spread of aerosol, since ICU patients undergo several aerosol generating procedures such as intubation, high flow nasal oxygen, bronchoscopy, and noninvasive ventilation. The requirement for ICUs is 1 tonne air conditioner for every 250 sq feet area, hence a 10 bed ICU needs appx 10 tonne Air conditioning. As per the WHO recommendations for COVID ICU HVAC systems, there should be a minimum of 12 air changes per hour. Fresh air should be encouraged-recirculation should be avoided. If recirculated air is used then HEPA filters must be used and periodically cleaned and maintained. The details of the HVAC system requirements for ICUs including COVID ICUs have been discussed in a recent review article.
Negative pressure rooms are ideal for managing patients who have highly infectious diseases that spread by droplets and aerosols, and COVID is one such disease. If feasible, negative pressure rooms must be included in ICU planning. However, if these negative pressure rooms cannot be created at short notice then, a well-ventilated ward would suffice.,
Adequate and earmarked spaces should be available for donning and doffing of PPEs by staff. These rooms should also be air conditioned.
A double door entry area is preferable for safe exchange of items such as food and other supplies. The outside team opens the outer door, and places the item in the area between the two doors and closes the door. Once they close the outer door, then the inside team opens the inner door to collect the items. Both the doors should never open at the same time.
In addition, the facility should have dedicated toilets for patients and staff. Area for hand washing with adequate supply of running water and soap should be assured and all surfaces of the ward should be amenable to cleaning since frequent cleaning will have to be resorted to. The detailed infrastructure requirement is shown in [Table 5].
Biomedical waste management
Detailed attention to handling, segregation at source using appropriate color bags, transport, and disposal of biomedical waste is a must to prevent infection. The use of dedicated bins placed inside the ICU in an area away from the patients and staff, use of double bags for segregation at source, proper disposal of the waste generated and safe transport by dedicated, trained staff with correct disposal is paramount to ensure safety of all housekeeping staff, patients, health-care personnel and other hospital staff. Cleaning of the ICU floor every four to 6 h by wet mopping and wiping the walls twice a day with disinfectant solutions like sodium hypochlorite (1%) should be ensured while medical equipment should be frequently cleaned as per institutional policy and/or recommendations of the manufacturer. The furniture in the ICU should also be wiped clean with disinfectant solutions to prevent spread by fomites.
Any infected material to be disposed of in yellow bins with yellow biomedical waste collection bags. The waste should be labeled “BIOHAZARD COVID-19 WASTE.”
The area dedicated for doffing must have its own set of biomedical waste bins for safe disposal of the PPE by staff who have finished their duty. Clear signposting should be done as to which article of the PPE should be discarded in which bin and what is the sequence of removing the PPE. N95 mask and the inner pair of gloves should be removed outside the COVID ICU. Hence, another yellow bin with yellow bag is required outside the ICU in a place with minimal movement of staff and patients.
Stool and urine should be discarded in the commode after adding 500 ml of 1% sodium hyoochlorite in the commode. After this the lid of the commode should be closed before activating the flush. The lid of the commode should be kept closed till next use.
Management of medical logistics
Medicines and medical disposables needed for the patients should be made available as in normal circumstances. Of special importance is the need to ensure adequate and regular supplies of PPEs for all the staff with anticipation of disruptions to the supply chain of this item especially during a pandemic when supplies are scarce. Adequate supply of disinfecting agents for environmental cleaning and prompt repair services for critical equipment should be ensured.
One of the most important logistic issues is to maintain a steady supply of oxygen. COVID 19 patients who are admitted to ICU invariably have requirement of oxygen or ventilation. Some of them might require high-flow oxygen therapy which consumes a large amount of oxygen. The amount of oxygen and related stores required for running a 10-bedded COVID ICU is given in [Table 6]. During planning phase, it is wise to overestimate rather than underestimate the requirement of oxygen.
| Discussion|| |
Given the worldwide experience, the health-care system has to prepare for handling a large number of COVID-19 patients needing intensive care. Measures put in place in our country since the nation-wide lockdown has provided time for health-care facilities to plan and activate additional resources to scale up to cater to the anticipated number of COVID patients needing critical care.
It is advisable to have separate, dedicated ICUs for COVID-19 patients to prevent cross-infection of other non-COVID patients.,,, In order to achieve this, new ICUs could be set up in existing wards by providing medical gas pipelines, air conditioning, extra electrical points at every bed (appx 6 combined points of 15 and 5 Ampere), generator backup, etc. This can be achieved by cancelling all elective admissions including surgeries in existing health-care facilities and thereby freeing up beds and human resources to dedicatedly deal with COVID-19 patients.,, While this may be possible on larger scales for normal isolation beds, critical care beds may be limited. In such a scenario, China had deployed Field Hospitals with Critical Care and Observation Wards where some initial level of critical care and intense observation was provided. When indicated, the patient from such a facility was transferred to the designated COVID-19 Hospital which had the necessary facilities.
The number of beds in the ICU has been kept at 10 to optimise efficiency and to cater to the nature of patients and anticipated workload. Also factored in is the fact that infection control practices have to be robust and implementable. The ten-bedded unit is in line with the norm, as well as what is recommended by the Experts Committee of the Indian Society of Critical Care Medicine.
Though the initial Chinese report estimated about 5% of COVID-19 patients needing ICU care, the Lombardy experience mentions 16% needing intensive care. Based on these data as well as the profile of the illness, each ICU bed needs to be provided with a dedicated ventilator. The increased number of ventilators needed can be obtained from non-COVID-19 hospitals in the region. It is interesting to note that in Australia, survey of ventilators in veterinary facilities revealed 95% of such ventilators to be human models. It is also pertinent to mention that splitting of output from a single ventilator to cater to multiple patients is being experimented with but is neither approved nor recommended for use., All other equipment recommended for each bed are based on the profile of patients needing multi-organ support with the aim of minimizing movement of equipment and personnel between patients and is in agreement with the recommendations of the COVID-19 Medical Inventory proposed by the Government of India. Three of the authors of this article were members of the Armed Forces Medical Services team that has compiled this medical inventory for the O/o the Principal Scientific Advisor to the GoI. The link to the website is available in [Table 7].
It is likely that adequately trained ICU staff may not be available in desired numbers. In such a scenario, reorientation, short training of available medical staff and their utilization in the ICU is the only way out.,, Online courses which are being offered free of cost may be used to train the staff at short notice. A suggested list of online resources for such training of medical staff is shown in [Table 4]. While a number of papers recommend staff working in shifts, the duration of each shift is left to the individual institution. In addition, the policy on the number of days to keep personnel on duty before giving them a 14-day break to lower the chances of infection in health-care workers is again, left to the institution.
It is pertinent to mention that this paper discusses a proposal to address only the establishment of intensive care facilities in the setting of COVID-19 pandemic and may not be applicable to the establishment of an ICU under normal circumstances. To cater to clinical variations in the severity and nature of organ involvement in COVID-19 patients, no specific recommendations have been made in terms of drugs and disposables required as these are the similar to a regular ICU and may vary with the local practice and preferences. Linen and other housekeeping requirements have not been mentioned specifically in this article. Recommendation on these aspects and calculations for requirements of PPEs are also available online.
This article specifically deals with the setting up of a new 10-bed ICU for COVID-19 patients. For guidance on how to start COVID-19 acute care facilities within an existing hospital the readers could refer to the commentary by Jog et al., which deals with topics such as administration, organization of hospital space, staff and supplies management, maintenance of standard of care, and specific COVID ICU management. The Indian Society of Critical Care Medicine has also issued a comprehensive position statement, on Critical Care of COVID-19 patients that deals with preparedness of the ICU for COVID 19 patients, staff and institutional capacity, training and healthcare worker assurance, critical care triage and allocation, equipment, logistics and capacity, communication, infection control ad biomedical waste management, treatment strategies, and post-ICU care.
| Conclusion|| |
The COVID-19 Pandemic has changed the world in unprecedented ways. It has posed several challenges to hospital administrators and health-care workers. Although about 85% of COVID 19 patients have mild disease and do not burden the hospital resources, it is the 15% moderately severe or critically ill patients who require ICU care or high dependency unit, who consume a large amount of medical resources - both material and human.
This article provides a framework to setup a 10 bed COVID-19 ICU in a short duration, under the present challenging circumstances. Sound planning in advance, good communication at all levels, training and motivation of staff, ensuring continuity and quality of medical supplies and efficient housekeeping services, combined with good logistics support to staff will ensure the success in the combat with COVID-19.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]