From intensive care to step-down units: Managing patients throughput in response to COVID-19

Abstract

Quality problem The ongoing COVID-19 pandemic may cause the collapse of healthcare systems because of unprecedented hospitalisation rates. Initial assessment 8.2 individuals per 1,000 inhabitants have been diagnosed with COVID-19 in our Province. The hospital predisposed 110 beds for COVID-19 patients: on the day of the local peak, 90% of them were occupied and intensive care unit (ICU) faced unprecedented admission rates, fearing system collapse. Choice of solution Instead of increasing the number of ICU beds, the creation of a step-down unit (SDU) close to the ICU was preferred: the aim was to safely improve the transfer of patients and to relieve ICU from the risk of overload. Implementation A 9-bed SDU was created next to the ICU, led by intensivists and ICU nurses, with adequate personal protective equipment, monitoring systems and ventilators for respiratory support when needed. A second 6-bed SDU was also created. Evaluation Patients were clinically comparable to those of most reports from Western Countries now available in the literature. ICU never needed supernumerary beds, no patient died in the SDU, there was no waiting time for ICU admission of critical patients. SDU has been affordable from human resources, safety, and economic points of view. Lessons learned COVID-19 is like an enduring Mass-Casualty Incident. Solutions tailored on local epidemiology and available resources should be implemented to preserve efficiency and adaptability of our institutions and provide adequate sanitary response.

Description of an Integrated and Dynamic System to Efficiently Deal With a Raging COVID-19 Pandemic Peak

“…The 4th floor, under the control of the intensive care department, thus counted on the following: 16 GW C19 beds, 1 intensivist, 8:1 PPNR; 9 beds SDU, 1 intensivist, and 3:1 PPNR (at least 1 ICU-trained nurse); 11 ICU1 beds, 2 intensivists (1 during the night shift), and 2:1 PPNR; 7 ICU2 beds, 2 intensivists (1 during the night shift), and 2:1 PPNR; 6 ICU3 beds, 1 intensivist, and 2:1 PPNR (Figure 1). Admission criteria to SDU were previously described (1).…”

“…Since its onset, the COVID-19 pandemic has pressured healthcare systems worldwide. We previously described a functional and dynamic strategy that allowed our intensive care unit (ICU) to deal with the first two peaks of the pandemic, in March and October 2020, that in our community reached 8.2 cases per 1,000 inhabitants (1). The setting is a public hospital of 450 beds, which is a reference point for a population of about 210,000 people.…”

Regional anesthesia in the intensive care unit: a single center’s experience and a narrative literature review

“…The ICU where the analysis was performed serves as a Hub center for trauma, neurosurgical, and neuroradiological conditions. The number of beds historically was 18, which increased to 23 from March 2020 [ 38 , 39 ].…”

Description of an Integrated and Dynamic System to Efficiently Deal with a Raging COVID-19 Pandemic Peak

“…Admission criteria to SDU were previously described. 1 This was made possible by a drastic 50% reduction of the planned operating room activity, actuated for safety reasons, that allowed to recover a su cient number of anesthetists to be employed at 4th oor. In Italy, anesthesia and intensive care still constitute a single residency program, thus specialists are certi ed and trained to manage complex patients with one or more ongoing organ failure.…”

“…We previously described a functional and dynamic strategy that allowed our intensive care unit (ICU) to deal with the rst two peaks of pandemic, in March and October 2020, that in our community reached 8.2 cases per 1,000 inhabitants. 1 The setting is a public hospital of 450 beds, reference point for a population of about 210,000 people. Before COVID-19, the ICU consisted of 18 beds; during the pandemic, 6 non-COVID ICU beds and 9 stepdown unit (SDU) beds were opened.…”