Preparation for SARS-CoV-2 pandemic in South Wales: practical steps
On 28 February 2020, the first case of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) originating from Wuhan, China was diagnosed in Wales [1]. The patient contracted the infection during his visit to Lombardy, where the outbreak in Northern Italy started to get a foothold [2]. At this stage, the official Welsh strategy was containment and preparation for a potential outbreak, in line with the rest of the UK. The Welsh NHS was asked to revisit plans for increasing critical care capacity by 100%, based on previous pandemic responses in the UK [3]. Based on the emerging data from Italy, where existing critical care capacity was quickly overwhelmed, decided to start preparations not just to plan, but actually execute the necessary increase of critical care beds on the 6th March 2020.
Aneurin Bevan University Health Board in South East Wales provides services for approximately 639,000 residents, about 20% of the population of Wales. In this organisation there are a total of 23 critical care beds, 16 within the Royal Gwent Hospital and seven within Nevill Hall Hospital, with capacity to provide invasive mechanical ventilation in 13 and six beds respectively. This translates to approximately 3.6 beds/ 100,000 population, one of the lowest in Europe and a stark contrast to the 7.2 beds/ 100,000 population at the start of the outbreak in Lombardy. Similarly to Northern Italy, the typical bed occupancy in Wales is close to 90-95%. We estimated that, even doubling capacity, we would not be able to meet the projected demand for critical care from this low baseline.
Mitigating the situation
To try to mitigate the situation, we started several parallel activities on the 6th March:
identification of appropriate physical areas to provide care for both SARS-CoV-2 positive and uninfected patients; development of processes for safe donning and doffing the personal protective equipment (PPE) at various levels of capacity on the SARS-CoV-2 ICU; training including simulation and other practical sessions to train the whole critical care multidisciplinary team on appropriate use of PPE, infection control practices and respiratory interventions such as prone positioning.
One of our Consultants took the lead on developing detailed guidelines for the above issues, and for general care of patients with SARS-CoV-2 infection based on the best available evidence [4]. Nursing staff and allied healthcare professionals worked over the weekend to map workflows, mostly around safe PPE use based on different scenarios and patient numbers. Plans were circulated electronically using WhatsApp groups, and the first official version of the ICU plan was ready by Monday morning. As clinical workload allowed, we started simulation and practical training of all critical care staff.
This has paid off as on the 9th March the first patient with suspected (later confirmed) SARS-CoV-2 infection was admitted to the hospital. He showed the typical clinical signs and clinical course of the severe disease, and was intubated using full PPE precautions in the negative pressure side room of the ICU.
A broad range of skills
The Critical Care team realised that any escalation of patient numbers could quickly overwhelm the original footprint, and presented the plans to the monthly Quality Improvement meeting of the Anaesthetic Directorate with an invitation to anaesthetic colleagues to form a united front for the challenge. Members of the anaesthetic department have a very broad range of skills ranging from pre-hospital military background to specialists in several subspecialty areas, and the department includes members of the senior hospital management team. In addition, several of them have been contributing to the Critical Care rota until recently. We have drawn upon their specific expertise and formed several groups to initiate rapid training of medical and theatre staff so that they can contribute to the critical care of SARS-CoV-2 and non-SARS-CoV-2 patients, whilst maintaining core emergency anaesthesia service in the hospital.
Via close liaison with the Executive Team of the Health Board, elective inpatient surgery was stopped, whilst urgent cancer and day-case surgery continued to free up staff time and to help reducing the burden of inpatient beds.
In the next two days, we ensured that PPE training was completed for all clinical staff in the anaesthetic and theatre teams, rapidly developed a simple protocol for safe and effective mechanical ventilation using the ventilators in the anaesthetic machines, whilst adhering to best practice guidance and simulation scenarios for practical procedures and mechanical ventilation problems [4]. We adapted a daily checklist tool, reflecting local guidance to streamline and standardise the care of SARS-CoV-2 infected patients (checklist courtesy of Dr Matt Morgan, Consultant Intensivist, Cardiff). A communication hub was developed, with the help of the administrative staff of the department, using existing hospital infrastructure and secure mobile messaging tools. We have reached out to the hospital informatics service to ensure appropriate communication devices are available at the bedside and for telepresence as appropriate.
Maintaining core services
In the meantime, members of the anaesthetic department started liaising with other specialties such as obstetrics and paediatrics to ensure that core services could be maintained, and that these more remote areas were also prepared for the care of infected patients.
Strategic aspects of disaster management are well described in the literature, and we would only like to offer some very practical points to consider when looking at expanding the critical care footprint into operating theatres [5].
Operating theatres normally have linked airflow management and are positive pressure areas. It is important to liaise with estates management on the optimal sequence of turning these positive pressure areas off to minimise infection spread and contamination. Increasing the flow through anaesthetic ventilators plus expanding the Critical Care footprint, together with increased oxygen use on the general wards, can deplete the oxygen stores of the hospital. Close collaboration with estates and oxygen suppliers is vital to maintain operational capabilities. Operating theatre complexes usually have adjacent changing facilities, which can make them ideal for safe donning and doffing of PPE and also offer some rest facilities for the staff. There are challenges in stocking appropriate pharmaceuticals throughout a large area, and our plan involves using volatile anaesthetic agents for sedation in patients looked after in the operating theatres, partly to maintain a more familiar environment for the anaesthetic staff and partly to reserve intravenous sedatives for other Critical Care areas. We have developed grab bags for airway management, dedicated trolleys for invasive line insertion for the SARS-CoV-2 infected patients, and recommissioned ultrasound machines for this and other rapid assessment purposes. Although most of the imaging information to date comes from CT, anecdotal reports from China confirmed that lung ultrasound can be useful to distinguish whether higher PEEP or prone positioning is more appropriate [6-8]. As this modality is readily available for us, rapid, focused teaching of the recognition of major lung pathologies is ongoing by the accredited ultrasound trainers of the group, using teaching materials from the national point-of-care ultrasound course [9].
Staffing is the biggest concern, as absence due to sickness and other personal emergencies is inevitable. Working with the UK national bodies, we have adopted a safe practice guidance for non-critical care staff working in an unfamiliar environment. We continue to use all available resources including in-situ simulation, online and other distance learning methods, developed either in-house or nationally, to be best prepared for the care of SARS-CoV-2 infected patients and to maintain the highest standards possible for our general critical care and anaesthesia population.
Wellbeing is paramount
Current official UK predictions state that the peak of the pandemic is approximately 10-13 weeks away, with a considerable tail behind. To maintain our operational capacity throughout this period, staff wellbeing is paramount. We have adopted and continue to promote the national guidance on this issue, and will utilise our well-developed internal resources [10].
Prof Maurizio Cecconi, the President-Elect of ESICM, issued a dramatic warning and plea to the world-wide critical care community on the 4th March 2020. He urged us to prepare and get ready as we are lagging a few weeks behind Italy. We agree that training and support of medical nursing and allied health care professionals is paramount in the short window we have before the patient numbers increase. We have identified that, instead of increasing capacity by 100% as requested by the Welsh Government, we have a possibility to quadruple the number of critical care beds within our organisation.
Our experience is that with shared understanding, clearly delegated tasks and using the social network and camaraderie of the critical care and anaesthesia community we can prepare for the SARS-CoV-2 pandemic.
SUPPLEMENTARY CONTENT AVAILABLE AT: grangecriticalcare.com
Tamas Szakmany
Consultant in Adult Critical Care and Anaesthesia,
Royal Gwent Hospital
Newport
Acknowledgments: members of the Critical Care and Anaesthesia Groups.
References
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