ObjectivesTo safely expand and adapt the normal workings of a large critical care unit in response to the COVID-19 pandemic.MethodsIn 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.ResultsCompared 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.ConclusionsWe 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.
Summary It is unclear whether the association between vasopressor dose and mortality is affected by duration of administration. We examined whether prognostication in septic shock is feasible through the use of daily median vasopressor doses. We undertook a single‐centre retrospective cohort study. We included patients with a diagnosis of septic shock admitted to the intensive care unit at Queen Elizabeth Hospital, Birmingham, UK, between April 2016 and July 2019. The primary outcome measure was 90‐day mortality. We defined vasopressor dose as the median norepinephrine equivalent dose (equivalent infusion rates of all vasopressors and inotropes) recorded for each day, for the first four days of septic shock. We divided patients into groups by vasopressor dose quintiles and calculated their 90‐day mortality rate. We examined area under the receiver operator characteristic curves for prognostic ability. In total, 844 patients were admitted with septic shock and had a 90‐day mortality of 43% (n = 358). Over the first four days, median vasopressor dose decreased in 93% of survivors and increased in 56% of non‐survivors. The mortality rate associated with a given vasopressor dose quintile increased on sequential days of septic shock. The area under the receiver operator characteristic curves of daily median vasopressor dose against mortality increased from day 1 to day 4 (0.67 vs. 0.86, p < 0.0001). By day 4, a median daily vasopressor dose > 0.05 μg.kg‐1.min‐1 had an 80% sensitivity and specificity for mortality. The prognostic utility of vasopressor dose improved considerably with shock duration. Prolonged administration of small vasopressor doses was associated with a high attributable mortality.
Chronic refractory angina pectoris (AP) affects 600,000 to 1,800,000 Americans, with approximately 50,000 new cases annually. A recent study revealed long-term mortality of refractory AP to be lower than previously reported, with >70% of patients living >9 years. Treating AP can improve quality of life. We describe a patient with refractory AP who underwent a successful stellate ganglion block for symptom control.
As our population ages, there will be an increasing number of extreme elderly patients (aged 85 years and older) admitted to intensive care units (ICUs). Relatively few studies are published about clinical outcomes in this population. We analysed three years of admissions data to the ICU of a teaching hospital in the West Midlands for patients who were aged 85 years or older at time of admission to ICU. Data from 185 patient episodes were included in the analysis. Six-month mortality in medical and surgical emergency patients was 62.5% and 55.1% respectively. Mortality was low in elective surgical patients at 18.6%. For those who survived the acute hospital admission, 68% of patients were discharged home, with a further 17% moving to a rehabilitation facility. A significant proportion of extreme elderly patients admitted to the ICU are surviving critical illness despite advanced age. The majority of survivors returned home, indicating that they were making a positive functional recovery from their illness.
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