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Repurposing a Neurocritical Care Unit for the Management of Severely Ill Patients With COVID-19: A Retrospective Evaluation

Raith, Eamon P. MBBS, MACCP, PhD*,†,‡; Luoma, Astri M.V. MBChB, FRCA, FFICM*,†; Earl, Mark MBChB, MRes, FRCA*; Dalal, Meera MPharm*; Fairley, Sandra RN*; Fox, Felicity RN, BSc*; Hunt, Katharine MBBS, FRCA, FFICM*; Willett, Charlotte RN, MSc*; Reddy, Ugan MBBS, FRCA, FFICM*,†

Author Information
Journal of Neurosurgical Anesthesiology: January 2021 - Volume 33 - Issue 1 - p 77-81
doi: 10.1097/ANA.0000000000000727

Abstract

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel beta-coronavirus. On January 30, 2020 the World Health Organisation (WHO) Emergency Committee declared a Public Health Emergency of International Concern (PHEIC) and, on March 11, 2020, a pandemic.1

The UK Influenza Pandemic Preparedness Strategy 20112 describes a nonlinear approach, across 5 stages, to the management of a pandemic: Detection, Assessment, Treatment, Escalation, and Recovery (DATER). This is activated on the declaration of a PHEIC by the WHO, or by a level 4 national incident. The declaration of the COVID-19 PHEIC formally activated the UK pandemic preparedness detection phase, and initiated preparations for a pandemic response across Public Health England and the UK National Health Service. The United Kingdom first case of COVID-19 was reported on January 31, 2020, with a national lockdown beginning on March 23, 2020 when there were >6000 known cases.

The United Kingdom has in excess of 4000 adult intensive care unit (ICU) beds (6.6 beds per 100,000 population),3 but this is lower than the European average (11.5 beds per 100,000)4 or the ICU bed capacity in the United States (34.2 beds per 100,000 population).5 As a result, the COVID-19 pandemic posed significant challenges to UK health care services to ensure that ICU capacity was sufficient and that health care needs of local patient populations continued to be met.

In early March 2020, as the rate of COVID-19-related ICU admissions was escalating across the United Kingdom, our institution commenced planning for admissions of patients with severe COVID-19 to a neuro-ICU to support the local critical care network, which risked being rapidly overwhelmed by the high numbers of COVID-19 cases in London. This process involved repurposing a dedicated quaternary level neuro-ICU into a general ICU capable of managing critically ill COVID-19 patients, while maintaining access for admission of patients with urgent neurosurgical or neurological conditions. Our local pandemic response plan required major adaptation of institutional organization, and presented an enormous physical and psychological challenge for all staff involved.

Although integrated into a larger multispeciality University health care organization, our institution was designed and planned as a single-specialty center dedicated to neuroscience. We provide comprehensive services for the diagnosis, treatment, and care of patients with neurological and neurosurgical conditions, both elective and emergency. In normal circumstances, the neuro-ICU has a total of 23 beds: 13 level-3 ICU beds and 10 level-2 ICU beds. Level-2 ICU beds (often referred to as “high dependency” beds in the United Kingdom) are those with the capability to provide advanced monitoring and support for up to 2 organ systems (but not mechanical ventilation), whereas level-3 ICU beds are able to provide multiorgan support including mechanical ventilation.6 A total of 759 patients were admitted to our neuro-ICU in 2019.

The aim of this report is to describe the processes and institutional changes required to repurpose a neuro-ICU during the COVID-19 pandemic into 2 separate areas: one to manage critically ill COVID-19 patients, and the other to manage critically ill non-COVID-19 neuroscience patients.

METHODS

This project was registered as a local service evaluation (22-202021-SE). In keeping with institutional guidelines, no formal research approvals or ethics review was required.

We conducted a retrospective process analysis of the logistics involved in the repurposing of a quaternary level neuro-ICU to manage critically ill patients with COVID-19 while maintaining neuro-ICU access for urgent neuroscience referrals. In line with consensus recommendations,7 the process analysis of the pandemic response plan was divided into: (1) engagement and education; (2) development of surge capacity; (3) workforce planning; (4) system-level planning, coordination, and communication; (5) business and continuity of operations and; (6) ethical considerations.

We retrieved demographic data, diagnosis and outcomes from the electronic health care records of all patients admitted to ICU beds between March 1, 2020 and April 30, 2020. We report outcomes data, including length of ICU stay, duration of mechanical ventilation and ICU mortality, for this period. We also compare the number of neuro-ICU admissions during the reporting period with the same period in 2019. Data are presented as median (range) where appropriate. In this report, an ICU bed is one where either level-2 or level-3 care can be delivered.

RESULTS

A response plan was developed to rapidly expand ICU capacity (particularly the capacity to provide mechanical ventilation), aligning with proposed phased ICU pandemic response plans7 and surge continuum taxonomy8,9 described in national10 and international7–9 guidelines. We identified key areas to ensure sufficient neuro-ICU capability alongside provision of dedicated COVID-19 ICU beds, in association with strategies to optimize performance within a short timeframe (Fig. 1).

F1
FIGURE 1:
Timeline of COVID-19 intensive care unit (ICU) planning response and development of surge capacity during the COVID-19 pandemic. *Planning and response stages defined according to the UK Influenza Pandemic Preparedness Strategy 2011.2 HDU indicates high dependency unit; NHNN, National Hospital for Neurology and Neurosurgery.

Development of Surge Capacity

ICU Beds

The baseline neuro-ICU bed capacity at our institution was 23 beds (13 level-3 and 10 level-2 beds), distributed across 2 geographically separate areas. Over a 10-day period, we were able to increase total ICU capacity by 21.7% (to 28 beds) and the capacity to provide mechanical ventilation by 77% (to 23 level-3 beds); the 5 additional ICU beds were all level-3, and 5 existing level-2 ICU beds were repurposed as level-3 beds. 18 of the 23 level-3 ICU beds were designated specifically for the management of patients with severe COVID-19. Further expansion into the operating rooms and anesthetic recovery areas to facilitate an enhanced surge response was limited by oxygen and electricity supply to the building, configuration of air handling units and availability of patient ventilators.

All elective intracranial neurosurgery and spinal surgery was cancelled, with only emergency cancer and neurovascular surgery permitted. This included patients referred via the regional acute stroke pathway for endovascular thrombectomy as well as an additional brain tumor caseload following our institution’s designation as the pan-London neuro-oncology center early in the pandemic response.

Our surge response provided sufficient ICU capacity to accept all urgent neuroscience referrals, and assist load-sharing of critically ill COVID-19 patients across the local critical care network.

Medicines Management

A list of essential medicines used in the treatment of COVID-19 patients was created based on data from China; these included anesthetic agents, opioids, neuromuscular blocking drugs, antibiotics, and hemofiltration fluids. Stock levels were increased by 50% within pharmacy dispensaries and, locally, on the ICU. High-use medications were red-flagged and daily stock levels monitored to determine demand. Because of supply and stock-piling restrictions, it was necessary for the procurement team occasionally to purchase imported and unlicensed products if routine supply chains became exhausted. This led to challenges related to unfamiliar labelling and packaging of drugs, and also required changes to the electronic prescribing system to account for different drug strengths and formulations. Alternative ICU protocols were introduced in response to drug shortages during the peak of admissions, with changes to sedation and paralysis regimes (replacing shorter acting propofol, fentanyl and atracurium infusions with midazolam, morphine, and vecuronium or rocuronium infusions). Also, it was necessary for the dialysate used for continuous renal replacement therapy to be changed from a citrate, calcium free solution to an available standard potassium replacement fluid, with systemic anticoagulation.

Referral Pathways

Patients with severe COVID-19 were referred to our ICU via a network transfer hub following assessment for clinical stability by the daily co-ordinating consultant who also arranged and co-coordinated patient transfer. Neuroscience emergencies continued to be referred through relevant specialty (neurology and neurosurgery) pathways.

Ethical Considerations

Clinical decisions, treatment escalation plans, and resuscitation status for patients were discussed twice weekly at a multidisciplinary team meeting. A local critical care ethics team was available to guide difficult patient care-related decisions. Throughout the pandemic response, we ensured that patients’ relatives were provided with daily nurse-led and consultant-led telephone updates. Once permitted by national guidelines, families were also able to visit relatives who were dying, should they wish.

Workforce Planning

As ICU bed numbers increased, the specialist critical care nurse: patient ratios for level-3 beds changed from 1:1 to 1:4-1:6. The increased capacity for the nursing care of patients requiring advanced respiratory support was developed in line with national guidelines.11 A condensed ICU training program was provided to former ICU staff and redeployed ward nurses. Non-ICU nurses were provided with a brief induction to the ICU, and training in the basics of monitoring and care of a ventilated patient. New nursing roles were defined as: category A (previous ICU experience), category B (ward nurse with no ICU experience), and category C (nursing support worker). Nurses were grouped into teams led by 1 or 2 of the regular specialist ICU nurses with a combination of any 2 category A, B, or C staff. Each team was responsible for the care of 4 to 6 patients depending on patient acuity and workforce availability. Shifts were modified to ensure that staff could be rotated to provide adequate breaks, aiming for a maximum of 2 hours in personal protective equipment at a time, and to ensure that there was equal rotation between COVID-19 and non-COVID-19 ICU areas.

Senior and trainee medical staff from neuroanesthesia and neurosurgery were redeployed to support the regular neuro-ICU consultants and resident ICU staff. This required varying degrees of urgent retraining (see below), particularly following reallocation of neurosurgical trainees/fellows and consultants into an unfamiliar environment. Neurosurgical consultants, supported by neurocritical care consultants, were primarily redeployed to manage the (non-COVID-19) neuro-ICU patients. Anesthesia-led endotracheal intubation and patient proning teams ensured streamlined care. The proning teams comprised medical and nonmedical staff, including physiotherapists, radiologists, neurophysiologists, and neurosurgeons. The proning team met at fixed times to maintain efficiency and optimal patient care, with regular briefings and fixed protocols to minimize risks associated with the prone position. The neuroanesthesia and neurosurgical teams also continued to support the emergency neurosurgical workload.

Staff self-isolation policies in case of COVID-19 symptoms or a household member becoming unwell were guided by Public Health England protocols. Staff testing for COVID-19 was utilized when it became widely available after April 10, 2020. Staff rotas were designed to accommodate a 20% staff sickness rate, ensuring that our ability to provide support to all ICU beds was not affected.

Training, Engagement, and Education

Training and education needs for all staff groups were assessed and identified as previously described for a pandemic situation.12 Regular and redeployed junior medical staff on the ICU were at various levels of training and from different specialty-backgrounds, so it was necessary to develop and introduce a detailed training plan to provide updates on management of patients with multiorgan failure, including those requiring advanced respiratory support. Similarly, the ICU nursing team was regularly updated with the latest guidelines for the management of COVID-19 patients. Key areas included knowledge of COVID-19 and general approaches to management, as well as personal safety and wellbeing advice.

In keeping with our usual neuro-ICU practice of integrating comprehensive clinical guidelines and protocols into routine patient management, a COVID-19 ICU management guideline was developed. This was designed as a 2-sided action card that could be printed, easily reviewed and retained in ICU areas (Supplementary Digital Content 1: Care of the SARS-CoV-2 positive patient in neurointensive care, https://links.lww.com/JNA/A308). Further guidelines relating to the daily assessment of COVID-19 patients (Supplemental digital content 2: Daily assessment of the patient with COVID-19 for noncritical care trained doctors working in ICU, https://links.lww.com/JNA/A309), safe use of personal protective equipment and how to minimize risk during aerosol-generating procedures were produced based on national guidance.10

Seminars and medical simulation training sessions were held to practice modified procedural techniques. Intubation drills were conducted twice-weekly so that all airway-trained staff had experienced of at least one scenario in full personal protective equipment. Staff were trained in a standard approach to prone positioning13 through twice-daily sessions conducted following morning and evening nursing handovers. Updates relating to national guidelines for advanced life support were also provided.

Reducing ICU Demand

ICU demand was reduced primarily by stopping all nonemergency surgery as described earlier, although the designation of our institution as the pan-London neuro-oncology center to provide priority-one cancer surgery throughout the surge added some demand for critical care. In addition, ICU staff provided educational updates to ward-based neurology and neurosurgery clinicians which, in association with the introduction of consultant-led acute general medical cover on non-COVID-19 neurology and neurosurgery wards, allowed more patients than usual to be managed outside the ICU. A COVID-19 respiratory care pathway was developed for use in the noncritical care setting and disseminated to ward teams (Supplementary Digital Content 3: National Hospital for Neurology and Neurosurgery COVID-19 respiratory care pathway: noncritical care setting, https://links.lww.com/JNA/A310). To ensure clear communication and optimize patient management, the ICU staff coordinated a weekly general ward care multidisciplinary team meeting involving key stakeholders.

Outcomes

Between March 1 and April 30, 2020, there were 30 admission episodes of 29 patients with a positive polymerase chain reaction test for SARS-CoV-2 to the COVID-19 ICU. Twenty-three of these patients were transferred via the local critical care network COVID-19 referral pathway, and 6 were neurosurgical or neurological patients with concomitant COVID-19 infection. Patient demographics and ICU outcomes for the COVID-19 patients are shown in Table 1. Median (range) length of ICU stay was 9.9 (1.3 to 32) days, admission APACHE II score 17 (9 to 23), duration of mechanical ventilation 11 (1 to 27) days, and ICU mortality rate 41.4%.

TABLE 1 - Demographics and Intensive Care Outcomes of Patients With SARS-COV-2 Infection
Patient demographics
 Age (median, range) (y) 62.5 (29-74)
 Sex
  Male 21 (70)
  Female 9 (30)
 Body mass index (kg/m2) 27.64 (22.6-38.2)
Intensive care details
 APACHE II score (median, range) 17 (9-23)
 Concomitant neurological or neurosurgical diagnosis (n) 6
 Duration of mechanical ventilation (median, range) (d) 11 (1-27)
 Number (%) of patients requiring proning 18 (60)
 Duration of proning (median, range) (d) 6.5 (1-11)
 Number (%) of patients with AKI requiring hemofiltration 6 (20)
 Length of ICU admission (median, range) (d) 9.9 (1.3-32)
 Mortality, n (%) 12 (41.4)
Thirty admission episodes of 29 patients; 1 patient had 2 admissions.
AKI indicates acute kidney injury; APACHE II, Acute Physiology and Chronic Health Evaluation II; ICU, intensive care unit.

During the same period, there were 78 neurosurgical or neurology admissions to the non-COVID-19 ICU, including 11 patients with intracerebral hemorrhage, 9 with subarachnoid hemorrhage, 9 with thrombo-occlusive stroke, and others requiring advanced postoperative monitoring or management of infections. This represents a 44% reduction in admissions compared with the usual neuro-ICU caseload; 140 patients were admitted to the neuro-ICU between March 1 and April 30 in 2019 and 78 patients in the same period in 2020. In particular, there was a 59%, 54%, and 59% reduction in the number of patients admitted with subarachnoid hemorrhage, intracranial hemorrhage and thrombotic stroke, respectively, during the COVID-19 surge.

DISCUSSION

In this report we present our experience of repurposing a dedicated neuro-ICU to manage patients with severe COVID-19 in a pandemic situation. The 41.4% ICU mortality rate amongst severe COVID-19 patients in our ICU compares favorably with the overall ICU COVID-19-related mortality (43.2%) in England, Wales, and Northern Ireland reported by the Intensive Care National Audit and Research Centre (ICNARC) at the end of May 2020.14 The 44% reduction in non-COVID-19 neuro-ICU admissions to our institution is in line with the reduction in UK Accident and Emergency Department admissions during the COVID-19 peak.15

As the UK lockdown eases and COVID-19 hospital admissions continue to decrease, the significant impact of the pandemic on nonurgent neurosurgery has to be addressed. The risk of a second COVID-19 surge necessitates maintaining rapidly accessible ICU beds, while allowing for a return to previous levels of neuro-ICU admissions to facilitate the resumption of elective neurosurgery. Such planning will have to take account of the persistence of COVID-19 transmission in the community, and requires novel approaches to the admission and in-hospital management of patients. The ICU bed capacity at our institution will now be serviced to account for patients that are COVID-19 positive, COVID-19 negative and of unknown status. The success of this approach is dependent on the availability of local, reliable, and large scale rapid diagnostic testing.

A successful pandemic response plan is defined by effective leadership, direction, and enabling conditions, in parallel with bottom-up dissemination of expertise and experience early in the preparatory phase. Resources, equipment and real estate availability are obvious challenges that have to be overcome. However, it is the adaptability and resilience of staff that drive a successful pandemic response; without successful staff engagement, education, and training, any response is doomed to failure. We believe that transferring our usual practice of integrating comprehensive clinical guidelines and protocols into routine patient management in addition to regular education and training enabled us to deliver a high standard of care to patients with severe COVID-19 while maintaining access for urgent neurosurgical and neurological patients.

ACKNOWLEDGMENTS

The authors would like to acknowledge the support and hard work of the Neurocritical Care and Neuroanesthesia teams during this extraordinary time. Without their support and engagement, it would not have been possible to provide care for patients with severe COVID-19.

REFERENCES

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Keywords:

COVID-19; coronavirus; neurointensive care; outcome

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