As COVID-19 was sweeping through the nation, Beth Israel Deaconess Medical Center (BIDMC) in Boston was preparing for a projected influx of critically ill patients in need of hospitalization. Although it was anticipated that workflow would need to change, the full impact of the pandemic for the medical center was unknown, causing increased uncertainty. It rapidly became apparent that a plan for the arrival of highly infectious, critically ill patients, as well as a strategy for adequate staffing, protecting employees and assuring the public that this could be managed successfully, was needed.
The ability of an organization to accommodate a large influx of patients for a prolonged period is dependent on surge capacity. Beth Israel Deaconess Medical Center, a 673–licensed-bed teaching hospital affiliated with Harvard Medical School, faced previous surge emergencies, such as the Boston Marathon bombing, which allowed the medical center to assess its response and make improvements for future events. To meet the demanding needs of this evolving emergency, the COVID-19 pandemic, BIDMC redeployed 150 staff to critical care and increased ICU bed capacity by 93%. 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 encountering an influx of critically ill patients during the pandemic.
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.1-3 To identify surge capacity, an organization must first consider the type of event to appropriately plan and leverage resources. Once the event is identified, organizations can plan for surge capacity, which is defined as the ability to obtain and maintain adequate space, supplies, and staff.1,2,4,5
Planning for an alternate critical care space has many challenges. Specific resources are required, such as increased access to electricity, oxygen, medical gas, and monitoring equipment, as well as the physical space to accommodate all of the additional equipment needed to manage an influx of critically ill patients.6 Hospitals have traditionally adapted existing capacity, including converting private rooms to doubles and using nontraditional spaces for other care areas.6 Reallocating space from canceled elective services and areas that have the capability for critical care monitoring such as postanesthesia care units (PACUs) should be considered.1,5,7,8 Strategies to increase bed capacity must be matched by staffing expansion and is impacted by the location of infected patients.9
During a pandemic, there is limited ability to increase the amount of intensive care unit (ICU) resources available, because shortages are often experienced nationwide.1,8 Preparations include detailed options for substituting, adapting, conserving, and reusing critical care supplies when appropriate. Supplies include both traditional and nontraditional equipment such as ventilators, medications, oxygen, vascular access devices, microdrip tubing, and 2-way radios.2,10,11
Planning requires comprehensive resource coordination, including monitoring of stock levels and maintaining records of incoming and outgoing flows of resources.7,12 The management of supplies within the hospital should be centralized to facilitate prioritization and distribution of items. Planning for immediate service provision must be balanced with preparing for future potential events.6 Stockpiling medical equipment and personal protective equipment (PPE) helps to mitigate the shortfalls of resources but is costly due to maintenance and storage.6
Increased critical care capacity is largely determined by the personnel skilled in managing critical care patients. To augment critical care staff to meet the sudden increase in volume, a team care approach is recommended.1,2,4 Health care workers, who have specific skills but lack experience in specialty areas, can work in teams supervised by those with relevant experience.1,4,8 Collectively, the group possesses the skills needed to manage and care for a group of critically ill patients.1,4,8 The Ontario Health Plan Report and the Society of Critical Care Medicine provide guidance for a team-based approach that incorporates shared staffing and cross-training to maximize the amount of staff available.1,4
Training and education using a multiapproach are an essential part of preparedness.10,13 The Society of Critical Care Medicine recommends the development of brief local ICU orientation models that focus on safe practices, unit hierarchy, and protocols.4,5 Training should be no longer than 4 hours and supplemented with additional resources to enhance course content, including just-in-time training, and emphasize infection prevention practices.1,4,5,8,10 Consistent, clear communication from designated sources further enhances staff safety.8,10,14
Team nursing shifts nursing care from individual patient outcomes to a model that maximizes the benefits of a larger patient population while maintaining standards of care.1,2,15 Nurses must be able to perform under stressful and suboptimal conditions and therefore need to be aware of their limitations including skills, knowledge, ability, and their expected role during a disaster.10,16 The review of the literature served as a way to structure the steps taken in our approach to disaster management.
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 (HICS) were used to clearly define roles, open lines of communication, and inform our surge plan (see Figure 1).5,17 Preparation began by collaborating with multidisciplinary groups to acquire the most appropriate space, as well adequate supplies, and identify and train staff.
An ICU Surge Planning Committee was convened and served as a subgroup of HICS (see Figure 1). At the first planning committee meeting, a walkthrough of all units identified as potential surge spaces was completed, and specific units were chosen to best meet the surge needs. Issues discussed were unit layout, proximity to existing ICUs, ability to close doors, and ventilator and hemodynamic monitoring capabilities.
The planning phase began in February, well before it was needed. The leadership team was informed by HICS that the trigger to escalate and open the surge areas would be when ICU capacity reached 70 patients. Once this occurred, there was a 12-hour window given to open the surge areas.
Multiple units were identified in planning for the surge: two 36-bed medical-surgical (MS) units, PACUs, and a neuro-intermediate care unit. The 2 MS units have 26 rooms, 10 are double rooms and 16 are private rooms. One of the units was specifically chosen because 7 beds were already in use as a vascular intermediate care unit. This large unit would give the hospital the ability to group together COVID-positive patients. Having COVID-positive floors allowed the hospital to cohort staff and contagious patients and protect noninfected patients.
In addition to increasing bed capacity, the space needed to be adapted to accommodate ICU workflow. The MS units were divided into 4 pods with an ICU team assigned to each pod. Preparing the monitoring capability for ICU-level patients began in earnest, and installation occurred as the number of critically ill patients increased. Workstations on wheels (WOWs) were added to facilitate charting outside the room, which would allow the nurses to be closer to and better visualize the patient. There was 1 WOW for every 2 rooms. Information technology added the critical care documentation system to these computers to meet the complex needs of the patients.
The neuro-intermediate care unit would be used as a COVID-negative unit for ICU patients. The semiprivate rooms were converted to private rooms because of space limitations related to critical care equipment. This effectively created a 9-bed unit. There was no pressurized room air in the headwall for ventilators; this necessitated using ventilators intended for more stable patients that did not require advanced settings. Two PACUs were also selected because they already had ICU monitoring capabilities.
The next phase of the ICU surge expansion called for daily monitoring of the capacity dashboard for the number of illnesses and rate of growth of the pandemic. Units would open when the projected rate of growth would exceed the current ICU capacity.
Intensive care unit carts were created and placed in the hallways to act as supply rooms for each pod. The goal was to mirror the medical ICU supply cart, with a plan to increase the number of supplies based on the number of beds within the unit. Par stocks of many supplies were increased to accommodate the anticipated influx of critical patients.
There would be a substantial number of staff needed to accommodate the overflow of critically ill patients. The hospital developed a recall list for former ICU staff, as well as identified procedural or PACU staff that could be called upon to be trained to care for critically ill patients. The plan was for usual ICU staffing ratios and then to convert to alternative staffing models as patient acuity and census dictated. Modifying the Ontario model, a decision was made to pair 1 ICU nurse with 1 MS nurse to care for either 2 or 3 critically ill patients. This was a team-based approach where staff were provided with specific roles and responsibilities (see Figure 2).
Two groups of redeployed nurses, MS nurses and former ICU nurses, would require education before transitioning into ICUs. Their unique skills, background, and function within the surge required different support and education. Two workshops were developed, one for each group. Conducting live in-person workshops with hands-on skill sessions while still maintaining social distancing posed a challenge, because many staff needed education.
For Registered Nurses (RN) with previous ICU experience, a 4-hour live workshop was developed. As the surge numbers began to rise, it became evident that in-person classes were no longer possible. Subsequent workshops were videotaped and were assigned via our learning management system.
For MS nurses, the intent was to capitalize on their preexisting skills that could be applied to a critically ill patient. The 4-hour workshop focused on reducing the fear and anxiety of the nurse, while promoting safety in several aspects of critical care, including ventilators, arterial lines, vasoactive infusions, and development of select new skills. The workshop included didactic presentations, hands-on skill sessions, a posttest, and a 4-hour shadow experience. Recognizing that most MS nurses were understandably anxious about their new role in an ICU, it was important to take time in the beginning of the workshop to provide reassurance that it was not the expectation that they learn critical care practice in 4 hours.
Because most MS nurses have limited or no exposure to ventilated patients, arterial lines, or patients with vasoactive infusions, it was essential that they receive basic knowledge on the equipment and terminology (see Table 1). Education on ventilators focused on basic safety measures such as the importance of restraints, how to safely turn and reposition patients who are intubated, when to recognize danger, and how to respond to ventilator alarms. A review of basic modes of ventilation and ventilator settings was included, as well as when to seek help.
TABLE 1 -
Content of MS Skills' Station
|Care of the ventilated patient
||• Care of the arterial line
||• Critical care infusions
|• Practice safe turning and repositioning
• Demonstrate in-line suctioning procedure
• Simulate oral care
|• Illustrate leveling of the arterial line
• Show the procedure for drawing blood off the line
|• Adjust critical care infusions using the IV pumps
• Practice closed-loop communication with ICU Registered Nurse
Abbreviations: ICU, intensive care unit; MS, medical-surgical.
Basic concepts were reviewed about the purpose of the arterial line and its setup, including the risk of dislodgement, air in the line, and to never administer medications via the arterial line. After arterial lines, central venous pressures were reviewed, including the purpose, the setup, and use of the stopcock for infusions. Next, the different classes of vasoactive drugs were discussed, and titration parameters were reviewed. Although MS nurses would not independently titrate vasoactive infusions, they could adjust it at the direction of the critical care nurse. The importance of paying close attention to decimal points, closed-loop communication, using smart pump technology, and double-checking the pump settings was emphasized. Because MS nurses would be responsible for documenting in the critical care documentation system, a brief tutorial of documentation standards was provided.
At the completion of the workshop, the nurses were given a 10-question posttest to assess retention and positively affect deeper learning.
After the workshop, nurses were assigned to shadow an ICU nurse to reduce anxiety, practice new skills, and gain confidence. Patient assignments were hand selected with preference for an intubated patient with invasive lines, which would enable the nurse to practice the newly acquired skills. When able, additional time was provided to any nurse requesting it.
Just-in-time training was provided, as well as printed documents of the educational topics, disaster documentation, roles and responsibilities, and troubleshooting tips for unstable patients.
The workshop for the former ICU nurses focused on refreshing skills they had previously acquired and practiced in their role as a critical care nurse. A 4-part lecture series was offered and focused on 4 key areas: care of the patient with adult respiratory distress syndrome, ventilator management, the use of vasopressors, and a review of the electronic documentation system (see Table 2).
TABLE 2 -
Lecture Series for Former ICU Nurses
|Lecture 1: Introduction and documentation
| • Review of our training plan
| • Introduction to our critical care documentation system
|Lecture 2: Adult respiratory distress syndrome
| • Pathophysiology
| • Management strategies
| • Case study
|Lecture 3: Ventilators
| • Modes and functions
| • Settings
| • Alarms
|Lecture 4: Vasopressors
| • Mechanisms of action
| • Review institution titration parameters
| • Case study
Abbreviation: ICU, intensive care unit.
IMPLEMENTATION OF ICU SURGE
Beth Israel Deaconess Medical Center has 9 specialty ICUs located on 2 campuses for a total of 77 beds. As the 70-patient capacity was met, the strategic surge plans began to unfold into nontraditional critical care spaces. As critically ill patients were moved into these areas, interdepartmental personnel quickly jumped into action to carry out the plans from the preparation phase.
The ICU leadership team carefully chose patients who could transition to the newly built ICUs. Patients chosen were stable on their ventilator settings, as well as pressors and sedation regimes. Initially, the plan was to admit all patients from the emergency department to the original ICU spaces with the goal of stabilizing them before transfer to the newly developed units. This was not always possible, and there were times when patients were admitted directly from the emergency department to the surge units. As the ICU census grew, original plans were followed, and adjustments were made with feedback from frontline staff now working in these new critical care environments (see Figure 3).
There were several issues with the MS space, and steps were taken to improve workflow and the safety of the patients. Of the 36 beds, only 2 rooms had windows built into the doors, and the nurses quickly identified this as a safety concern. Within 2 days, windows were cut into all other doors by the maintenance department, which allowed for visualization of the patients while keeping the doors closed to reduce staff exposure. Beds and equipment were then repositioned in every room to best visualize and assess each patient (see Figure 4).
As this unit grew, 2 patients were placed in rooms large enough to accommodate a second patient. Unfortunately, even with the newly constructed windows, it remained difficult to see the patient and hear their alarms if they were located by the window. After brainstorming, convex mirrors and baby monitors were acquired and placed in the rooms. These devices worked well and improved the ability to safely care for an increased number of patients.
It was also identified that there were too few electrical outlets in the hallways to accommodate all the equipment that was needed. Hospital electricians installed numerous outlets to meet this demand.
It was also necessary to transform any space not used for inpatient care. For example, the visitor's lounge was repurposed as a break room and wellness area to allow staff downtime and provide a large enough area for social distancing. The bathrooms were not near the patient rooms in 2 pods, which made it challenging for staff. A buddy system was developed to ensure enough staff remained in each pod when nurses needed to be away from the area.
To meet the increased census of ICU patients, critical care supplies and equipment were brought to all designated areas for deployment. Mobile supply carts were placed strategically in every space available such as hallways and patient rooms. Mirroring the medical ICU supply carts, however, was not as helpful as originally planned. Each unit had some of these supplies already available and in a location familiar to staff. This required a continuous reorganization and reallocation of supplies in real time to meet changing patient and staff needs.
As the influx of patients continued, it was noted that there were not enough WOWs present on the units to accommodate the number of providers who needed ongoing access to the hospital computer systems. At times, the network was slow and not functioning efficiently. These concerns were raised and promptly resolved. These patients required more equipment than was originally allocated. The institution bought more infusion pumps and rented different feeding pumps to meet this need. Changes to the content of and the addition of automated medication dispensing systems were made to best meet the needs of each location.
Medical-surgical and ICU nurses worked together to care for critically ill patients in surge units. The original plan to care for 8 patients with 3 ICU nurses and 4 MS nurses was revised because patients' acuity was far higher than originally anticipated (see Figure 5). The model that was used was 1 ICU nurse paired with 1 MS nurse caring for 2 or 3 patients. Some ICU nurses worked alone if their patient's acuity was appropriate. A typical staffing pattern for 34 patients included 17 ICU and 10 MS nurses. An example of a typical daily acuity included 31 ventilated patients, 11 patients on multiple vasopressors, 3 patients on Continuous Renal Replacement Therapy, 2 patients proning, and multiple patients traveling to computed tomographic scan and magnetic resonance imaging. Allied health professionals were deployed as part of a proning team and would often travel with the patients for safety and support. This team also rounded on a schedule to prone and supine patients.
As the surge peaked, doubling the ICU capacity, additional staff was deployed to surge areas. Staff shortages were mitigated by offering incentive pay. Just-in-time training was offered to all redeployed staff members. Mentorship of MS nurses by the critical care staff occurred in real time and was essential to the success of the model.
The nurses received shift report together and then made plans aimed at working collaboratively to monitor, assess, and provide care for their patients in this new environment. This approach was particularly important to provide safe and effective care. The nurses from the different care areas complemented each other as they brought their unique skill sets to the surge areas. For example, the floor nurses were more familiar with the unit layout and telemetry setup, whereas the ICU nurses were more familiar with the intensive care needs of the patient and critical care documentation system. Matching skill sets was important to maintain continuity in nurse-patient assignments as well as in nursing teams.
Support and communication in these new environments were ongoing and essential to provide safe, effective care to all critically ill patients. In addition, a need for 24-7 nursing leadership was noted, and an ICU nursing director provided this in-house support on the night shift.
Nursing leadership teams provided support via on-unit huddles twice a day. The bidirectional huddles allowed time and space to communicate information, ask questions, extract opportunities for improvement, and gain overall situational awareness. The nurse specialist group shared the responsibility of rounding on the surge units. It became evident that, because this was a shared responsibility, a templated huddle format and email communication were necessary to effectively communicate information and ensure appropriate follow-up related to care of the patients and operations of the units.
The nurse specialist led the huddle following the template that included an opportunity for introductions, creation of situational awareness, clinical updates, and time for questions. Key roles and individuals such as the 2 resource nurses for the shift, the medical teams, and their contact information were disseminated to the staff. Highlights of the information learned at the daily HICS call and any pertinent events from the previous 24 hours were also communicated. Staff communicated important patient information such as which patients on the unit were proning, approaching extubations, traveling for procedures, or transitioning to floor status. Staff were also provided the opportunity to raise any clinical or safety concerns. These were addressed in real time or communicated to leadership for further action when necessary. After the huddle, the nurse specialist provided an email report to the ICU nurse leadership team to evaluate unit acuity, inform decisions for staffing, and obtain additional resources.
Within our institution, the nurse scientist collaborated with nursing leadership and clinical nurses to respond to the COVID-19 pandemic using an evidence-based approach. Policies and practices were redesigned to meet the ever-changing needs of the institution, staff, and patients. The nurse scientist focused on working with interdisciplinary teams in the development and implementation of initiatives to support, protect, and sustain our limited health care resources in the pandemic, especially nursing resources. The COVID-19 pandemic not only highlights the exceptional care provided by clinical nurses and their interdisciplinary colleagues but also exemplifies how the integration of evidence, science, and experience was used for system change and patient-centered interventions for achieving positive patient outcomes.
The organization's commitment to patient care and staff-focused advocacy served as the driving force for the success of the work. Nearly doubling the normal capacity of ICU beds would never have been possible without a dedicated effort from multiple departments at the medical center. On reflection, there are some key points worthy of discussion.
The impact of the physical layout of the newly formed ICUs was underestimated, and many issues were experienced that needed to be addressed in real time. The large surge units could accommodate many more patients than traditional ICUs. The concept of dividing a large MS unit into 4 pods proved to be vital to smooth operations; however, it very quickly became apparent that these spaces needed to be looked at as 4 separate ICUs and not 1 unit.
Because the MS environment is not designed to deliver an ICU level of care, many modifications needed to be made. There was not enough space to accommodate 4 multidisciplinary care teams, multiple equipment carts, and storage of supplies and medications. Social distancing only added to the difficulties in rounding and huddling and made it extremely challenging to attain situational awareness in each pod. Furthermore, the rooms were designed for patient privacy and quiet. A key safety element in critical care is patient visibility. This was difficult because each surge space required a different intervention to meet this need.
Reallocating space such as PACU and areas that have the capability for critical care monitoring were repurposed during the surge. Although the literature frequently recommends using PACU space,1,4,6,7 the experience at BIDMC did not support this. The PACU environment may be an ideal space for many other types of disaster planning, but the open-floor plan and narrow patient bays separated by a curtain only complicated work streams in the setting of a novel-virus pandemic. Droplet and contact precautions required staff to wear PPE for prolonged periods. In addition, there was still a need for use of this space for operating room procedures. For these reasons, PACU spaces were reverted to their original use.
The stockpiling of medical equipment and PPE is a standard operating procedure, and there is a defined process in place to access and disperse these items in a pandemic.5,6 Because the number of patients who would require critical care was not fully appreciated, not enough supplies were allocated to these areas. The amount of PPE used alone was staggering. Keeping the par level up during the height of the surge was difficult. The patient care technicians spent a significant amount of time restocking rooms and the small bins strategically located throughout the unit. Finally, the laundry service's ability to keep enough gowns in circulation was an ongoing problem addressed daily.
These patients were also requiring large amounts of sedatives, analgesics, and vasoactive medications. Additional automated medication dispensing cabinets had to be added to some surge units, whereas other surge units adjusted their par levels, reducing some and increasing others.
Interdepartmental teams were involved in the planning for supplies that would be needed in the new ICU care areas. However, this was a repetitive process that required regular assessments to modify the par level of many items to meet the needs of the patients. The number of intravenous (IV) infusion pumps needed was underestimated. Each patient required at least 4 to 5 continuous infusions. Thankfully, more IV pumps were purchased, and the hospital did not have to explore alternative ways to deliver IV medications. Tube feeding bags and pumps were in short supply; a different pump and delivery bag were purchased and used at one of the hospital campuses providing plenty of supply. Innovative ways to obtain needed equipment such as nontraditional vendors as well as borrowing equipment from area pediatric and rehabilitation hospitals were a major source of stress that needed constant, aggressive surveillance. This was an iterative process with multiple changes along the way requiring frequent and clear communication with the distribution team. The situation was complicated by the fact that all acute care hospitals were struggling to obtain the same equipment.
Redeployment of staff required education and support. Although a plan was in place for the didactic and shadow experience, the spike in COVID admissions limited the ability of all nurses to complete the training before deployment. Just-in-time training on the unit supplemented by online education had to be used. The staff identified the shadow experience as being most beneficial in preparing them for deployment.
Consistent patient assignments and assigning familiar staff geographically was a lesson learned over time. Historically, this institution has strong collaborative relationships with staff from different areas and roles. These relationships proved to be vital to the success of all the care teams. The social work department played a major role in fostering teams, especially during difficult situations.
The importance of clear communication with staff cannot be overemphasized. Regular, structured rounding and huddles were remarkably effective. Multiple emails, particularly emails sent out late in the evening (especially on Fridays), were less successful. This was a challenge because there was less leadership support to alert the staff in person of acute changes, such as frequent PPE changes.
The hospital worked to provide some built-in support with weekly debriefing sessions. Scrubs were also provided for staff who wanted to change at work. Family meals and essential groceries could be ordered at work from the cafeteria for take home. A wellness checklist was posted for the end of the shift for staff to take stock of their well-being, and hospital resources for stress support were posted.
As the surge resolved, “staffing down” became a new emotional bridge to cross. Staff were returning to their home units. This was both a relief and a stress. The staff had become an emotional support for each other during the surge. The critical care staff were experiencing the same stressors, and this created a bond and an informal support system. When they returned to their unit, they were no longer in touch. The staff moved back to COVID-capable units where COVID-negative and COVID-positive patients were collocated. On multiple occasions, staff expressed this was a difficult transition.
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. Planning for the surge of critically ill patients required a thoughtful, collaborative approach. The preparation phase was an important time where teams were formed to identify necessary resources to expand the ICU environment quickly and efficiently. Educational training including shadow experiences before the actual surge was valuable. 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.