Lessons Learned From the Rapid Expansion of Intensive Care Unit Care to the Operating Room During the Coronavirus Disease 2019 Pandemic.

Abstract

See Article, p 1182 New York City emerged as an epicenter of the pandemic in early March with cases peaking in the first week of April 2020. During the early phases of the pandemic, daily case rates rose quickly and led to a surge of patients requiring hospitalization. The anticipated number of increased hospital admissions raised concerns that current hospital capacity in the area would be overwhelmed. In response, Governor Cuomo canceled all elective surgeries and mandated the capacity of all hospitals be increased by a minimum of 50%.1 The cancellation of elective surgeries dramatically decreased daily surgical volumes at New York hospitals. As a result, several hospital systems converted underutilized operating room (OR) space into intensive care units to accommodate the increase of critically ill patients. In addition to spatial concerns, the anticipated high number of patients requiring mechanical ventilation could be addressed by admitting patients to the OR where anesthesia machines managed by anesthesia personnel could be utilized. In this issue of Anesthesia & Analgesia, Mittel et al2 describe and evaluate the management of critically ill patients while being cared for in their newly converted operating room intensive care unit (ORICU). The additional 82 beds gained by using the OR played a significant role in increasing their intensive care unit (ICU) capacity from 117 beds prepandemic to 257 beds at NewYork–Presbyterian/Columbia University Irving Medical Center (NYP-Columbia). In the article, they describe the challenges in reconfiguring the OR space and reorganizing their perioperative staff to care for these critically ill patients. This endeavor was complex and multifaceted and involved physical changes to the OR space, establishment of a central monitoring system, and the repurposing of anesthesia machines as ICU ventilators. In addition to the space and equipment challenges, the shortage of critical care trained personnel required a major restructuring of perioperative staff workflow. The authors performed an institutional review board–approved retrospective analysis of critically ill coronavirus disease 2019 (COVID-19) patient survival in the novel ORICU compared to patient survival cared for in more typical ICU environments. The overall 30-day survival from ORICU admission was 61% with higher mortality in patients ≥65 years of age. These results are consistent with findings at other health care institutions with a high volume of COVID-19 admissions and consistent with the overall NYP-Columbia health care system survival rates. The authors concluded that outcomes in COVID patients cared for in their ORICU were similar to COVID outcomes in their typical ICU environments. Mittel et al2 describe an extraordinary response to a near-unprecedented clinical challenge that many New York medical centers, including ours, faced. Due to the unusually dynamic nature of the COVID epidemic direct comparisons of outcomes between legacy ICUs and the ORICU are difficult. Initially, critically ill patients on high-dose vasopressors and patients with certain comorbidities (ie, heart failure and stroke) were sent to legacy ICUs rather than the ORICU as logistics allowed. Early technical challenges also prevented admission of patients requiring extracorporeal membrane oxygenation (ECMO) or renal replacement therapy (RRT) to the ORICU. Similarly at our institution, the small cohort of patients placed on ECMO were cared for only in the cardiothoracic ICU on our main campus. By congregating these patients, we were able to optimize the utilization of staff members already proficient with ECMO management. The number of patients requiring RRT prevented a similar cohorting strategy. At NYP-Columbia and at our institution, the ORs lacked the necessary water connections to operate traditional dialysis machines. The acquisition of additional central venovenous hemodialysis machines, which do not require a water connection, allowed us to care for patients in renal failure in units lacking ionized water connections. At Montefiore Medical Center, we addressed the COVID-19 challenge in a slightly different way. We increased our ICU capacity from 106 ICU beds pre–COVID-19 to a peak of 260 ICU beds in April 2020. The majority of our increased ICU capacity came from the conversion of non-OR spaces such as postanesthesia care units (PACUs), step-down units, and telemetry floors. However, OR space at the main campus, a satellite campus, and our ambulatory surgical center (ASC) were utilized for varying amounts of time during the pandemic. The majority of ORICU patients were cared for in our satellite campus from April 4 to April 31, 2020. A total of 11 critically ill patients spread across 6 ORs could be cared for at a time. The OR ventilation was changed from positive pressure to negative pressure for infection control, while the substerile core areas were designated for donning and doffing of personal protective equipment (PPE). Our staffing model varied significantly among the different newly created ICUs throughout the Montefiore system. The 4 critical care trained anesthesiologists in our department were assigned as needed by the multidisciplinary Critical Care Medicine service. Nurse anesthetists were assigned either to emergency departments or code teams to assist with intubations. The cardiac anesthesia group cared for non–COVID-19 surgical ICU patients in the PACU on the main campus. General anesthesiologists were assigned to various novel ICUs to assist with procedures and ventilator management and were also responsible for the care of patients assigned to the ORICUs at the different campuses. The housestaff in the ORICUs consisted of anesthesia residents. The nurses and support staff were a combination of PACU and OR nurses and the perioperative ancillary staff. We addressed the shortage of critical care trained physicians in a slightly different manner from that described at NYP-Columbia. When possible, critical care trained anesthesiologists rounded with the ORICU team to help with workflow and management issues. However, this solution became untenable due to increasing clinical needs throughout the hospital system. A critical care command center staffed by intensivists became operational on April 10, 2020, to provide remote support to nonlegacy ICUs such as our ORICUs. This included regular daily review of patient care plans with the ICU physician teams, continual availability for immediate questions and recommendations, as well as managing equipment and beds across the different hospital sites. In contrast, at NYP-Columbia critical care anesthesiologists oversaw the management of all ORICU patients. Their implementation of specialized care teams was also more extensive and delineated. Of particular interest to us was the creation of their Family Liaison team. Communication with patients’ family members was strained during this time as hospital visitation was heavily restricted and the OR space was not designed for visitors to see patients cared for in the OR. In our medical center, this inability to visit caused 2 major problems. Since the teams could not speak face to face with patients’ family members, families would call at all hours and interrupt workflow on rounds. In response, every family was called in the early afternoon and given an update. Families quickly adapted to this practice and the number of calls during rounds significantly decreased. The second problem was that family members could not see their loved ones. To alleviate this problem, we shifted to using electronic tablets to update families at the patient’s bedside using video calls. This practice was greatly appreciated by patients’ families, some of whom came to insist that all updates be made via video calls. The creation of the Family Liaison team at NYP-Columbia had a few advantages over our system. They helped to divest some of the workload from the critical care team actively managing the patients. Since the Family Liaison team physicians were not directly caring for the patient in person, they had more time to commit to family emotional support and could also remain a constant presence in the transmission of information to the family (as opposed to our ICU care teams which served 2-week-long blocks at a time). The Family Liaison service also provided a way for faculty members with higher medical risk factors to participate in a meaningful way without increasing their exposure risk. To care for up to 82 patients in the ORICU at NYP-Columbia, from 3 to 6 patients were cared for in each of the 23 ORs. When we opened the ORs on the main campus, we placed 4 patients in 1 OR. In our experience managing this unit, we found the negatives of this arrangement outweighed the positives. Space between patients was severely limited due to the large ICU beds, anesthesia machines utilized for monitoring and ventilation, medication carts, and additional bedside supplies and equipment. Noise pollution from alarms also hindered patient care. The initial intention was that by placing 4 patients in 1 OR, the staff would be able to don PPE once and enter the room and care for multiple patients, thus conserving PPE resources. However, the 4 patients could not be arranged with clear sight lines to facilitate monitoring from outside the OR, and staff ultimately needed to stay in the room for prolonged periods of time in tight working conditions. This particular ORICU was intended to be a bridge until the pediatric PACU space completed conversion into a 16 bed ICU and additional ventilators could be obtained. Initially, all patients admitted to our ORICUs were ventilated via anesthesia machines due to limited supply of ICU ventilators. Fortunately, we never needed to place multiple patients on 1 ventilator. Anesthesia machines were only used in units with adequate anesthesia personnel familiar with their operation as recommended by the Anesthesia Patient Safety Foundation (ASPF).3 As noted by Mittel et al,2 differences between traditional ICU ventilators and anesthesia machines created their own distinct challenges. As the supply of ventilators increased, care was transitioned away from anesthesia machines. Priority was given to patients with improving respiratory mechanics who were starting to wean. Once both requirements were achieved, the patients in the ORICU on the main campus were transferred to the pediatric PACU and the ORICU was closed. The lessons learned from this unit influenced patient care on our other campuses, where only 2 patients were cared for in each individual OR. The ORICU created at our ASC encountered many logistical challenges due to its geographical isolation, including supportive services such as dialysis, radiology, and laboratory and blood bank services on site. For these reasons, the care of critically ill patients was more efficiently handled at either the main campus or at 1 of the 2 satellite campuses and the unit was closed shortly after accepting its first patient. The ORICU on the satellite campus remained open the longest. As patients recovered and sedation was lightened, they were transferred to a more typical ICU setting. Weaning from the ventilator requires increased monitoring, which was more difficult in the physical layout of our OR ICU. We were concerned that an awake extubated patient in the OR would have an increased incidence of delirium due to the lack of windows and the psychological stress of having an intubated critically ill patient in the room with them. However, we note that unlike NYP-Columbia, the majority of our increased ICU capacity came from the conversion of non-OR spaces, which allowed us the ability to transfer patients out of the ORICU when they were recovering. The difference between the 2 health care system’s responses illustrates how each institution’s existing infrastructure, logistics, and individual community needs ultimately dictate the most suitable course of action. The COVID-19 pandemic is not yet receding, and at the time of this editorial, multiple states are reporting a rise in case number and hospitalizations.4 In these unprecedented times, it is clear that adaptation, innovation, and resilience are needed to contain the virus and treat its victims. It is clear from our experiences that each OR is not simply a 1-bed ICU. Nevertheless, as Mittel et al2 and we have demonstrated, it is not only possible to deliver prolonged critical care in an OR but also to do so with outcomes comparable to that of more typical ICUs. DISCLOSURES Name: Anastasia Meleties, MD. Contribution: The author helped write a significant portion of the manuscript and reference section. Name: Nicole Morikawa, MD. Contribution: The author helped write a portion of the manuscript. Name: Christopher Y. Tanaka, MD, FASE. Contribution: The author helped significantly with the writing of the OR to ICU conversion section of the manuscript. Name: Curtis Choice, MD. Contribution: The author helped significantly with the sections pertaining to the ambulatory surgical center. Name: Jay Berger, MD, PhD. Contribution: This author helped significantly in the preparation of the overall manuscript. This manuscript was handled by: Avery Tung, MD, FCCM.