Transforming a PICU Into an Adult ICU During the Coronavirus Disease 2019 Pandemic: Meeting Multiple Needs.
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ABSTRACT:
SUBMITTER: Levin AB
PROVIDER: S-EPMC7498134 | biostudies-literature | 2020 Sep
REPOSITORIES: biostudies-literature
Publications
Transforming a PICU Into an Adult ICU During the Coronavirus Disease 2019 Pandemic: Meeting Multiple Needs.
Levin Amanda B AB Bernier Meghan L ML Riggs Becky J BJ Zero Stephanie D SD Johnson Emily D ED Brant Katelyn N KN Dwyer Joe G JG Potter Caroline J CJ Pustavoitau Aliaksei A Lentz Thomas A TA Warren Emily H EH Milstone Aaron M AM Schwartz Jamie McElrath JM
Critical care explorations 20200915 9
We describe the process converting half of our 40-bed PICU into a negative-pressure biocontainment ICU dedicated to adult coronavirus disease 2019 patients within a 1,003-bed academic quaternary hospital. We outline the construction, logistics, supplies, provider education, staffing, and operations. We share lessons learned of working with a predominantly pediatric staff blended with adult expertise staff while maintaining elements of family-centered care typical of pediatric critical care medic ...[more]
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Project description:OBJECTIVES:Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. DATA SOURCES:PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. STUDY SELECTION:Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. DATA EXTRACTION:References and data were based on relevance and author consensus. DATA SYNTHESIS:We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. CONCLUSIONS:Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.
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Project description:The importance of promoting well-being for healthcare professionals has never been as important as during the current coronavirus disease 2019 pandemic. It is recognized that the concept of well-being is a multifaceted phenomenon which is influenced by individual, team, and system characteristics. We outline an approach to practically initiating supportive strategies within the PICU using a well-being approach to improve baseline resilience alongside an acute rescue strategy utilizing a peer-support network. These strategies are practical interventions and we share them with the aim of encouraging the international PICU community to use these or other strategies to support their teams. We encourage shared learning and collaboration during these difficult times.
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Project description:BackgroundHeightened public anxiety was observed at the early stage of the COVID-19 pandemic. Our study enriches scholarly understanding of this mass response by investigating both generic and pandemic-specific anxiety that explain preventive health behavior.MethodsIn our two-phase, mixed-methods study, pandemic-specific anxiety items elicited during the qualitative phase from March 2-8, 2020 were then tested in the quantitative phase from March 16-22, 2020. Eligible participants were U.S. or U.K. residents aged 18-65.ResultsOf the 1,400 participants, 52% met the criteria for moderate to severe anxiety. In addition to anxiety over possible personal COVID-19 infection, participants were also anxious about others' health, others' reactions (e.g., panic-buying, discrimination), societal problems (e.g., economic slowdown, healthcare system breakdown), and personal finances. The positive association between generic anxiety and hygiene practice frequency was explained by two interpersonal-oriented forms of pandemic-specific anxiety: anxiety over others' health (b = 0•0040, 95% CI: 0•0031-0•0050) and others' reactions (0•0031, 0•0021-0•0042).LimitationsThe study was conducted with participants from developed countries at an early stage of the pandemic, and the results were not necessarily generalizable to developing countries or other stages of the pandemic. Also, hygiene practices was the sole behavior of interest, and the findings may differ for other behaviors.ConclusionsThe new findings indicate the importance of adopting a nuanced approach that unveils the multifaceted nature of anxiety using a mixed-methods design. Individuals from COVID-19-affected regions experience pandemic-specific anxiety due to concerns related to not only personal but also interpersonal-oriented issues.
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Project description:ObjectivesGiven finite ICU bed capacity, knowledge of ICU bed utilization during the coronavirus disease 2019 pandemic is critical to ensure future strategies for resource allocation and utilization. We sought to examine ICU census trends in relation to ICU bed capacity during the rapid increase in severe coronavirus disease 2019 cases early during the pandemic.DesignObservational cohort study.SettingThirteen geographically dispersed academic medical centers in the United States.Patients/subjectsWe obtained daily ICU censuses from March 26 to June 30, 2020, as well as prepandemic ICU bed capacities. The primary outcome was daily census of ICU patients stratified by coronavirus disease 2019 and mechanical ventilation status in relation to ICU capacity.InterventionsNone.Measurements and main resultsPrepandemic overall ICU capacity ranged from 62 to 225 beds (median 109). During the study period, the median daily coronavirus disease 2019 ICU census per hospital ranged from 1 to 84 patients, and the daily ICU census exceeded overall ICU capacity for at least 1 day at five institutions. The number of critically ill patients exceeded ICU capacity for a median (interquartile range) of 17 (12-50) of 97 days at these five sites. All 13 institutions experienced decreases in their noncoronavirus disease ICU population, whereas local coronavirus disease 2019 cases increased. Coronavirus disease 2019 patients reached their greatest proportion of ICU capacity on April 12, 2020, when they accounted for 44% of ICU patients across all participating hospitals. Maximum ICU census ranged from 52% to 289% of overall ICU capacity, with three sites less than 80%, four sites 80-100%, five sites 100-128%, and one site 289%.ConclusionsFrom March to June 2020, the coronavirus disease 2019 pandemic led to ICU censuses greater than ICU bed capacity at fives of 13 institutions evaluated. These findings demonstrate the short-term adaptability of U.S. healthcare institutions in redirecting limited resources to accommodate a public health emergency.
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Project description:To create evidence-based consensus statements for restricted ICU visitation policies to support critically ill patients, families, and healthcare professionals during current and future pandemics.DesignThree rounds of a remote modified Delphi consensus process.SettingOnline survey and virtual polling from February 2, 2021, to April 8, 2021.SubjectsStakeholders (patients, families, clinicians, researchers, allied health professionals, decision-makers) admitted to or working in Canadian ICUs during the coronavirus disease 2019 pandemic.Measurements and main resultsDuring Round 1, key stakeholders used a 9-point Likert scale to rate experiences (1-not significant, 9-significant impact on patients, families, healthcare professionals, or patient- and family-centered care) and strategies (1-not essential, 9-essential recommendation for inclusion in the development of restricted visitation policies) and used a free-text box to capture experiences/strategies we may have missed. Consensus was achieved if the median score was 7-9 or 1-3. During Round 2, participants used a 9-point Likert scale to re-rate experiences/strategies that did not meet consensus during Round 1 (median score of 4-6) and rate new items identified in Round 1. During Rounds 2 and 3, participants ranked items that reached consensus by order of importance (relative to other related items and experiences) using a weighted ranking system (0-100 points). Participants prioritized 11 experiences (e.g., variability of family's comfort with technology, healthcare professional moral distress) and developed 21 consensus statements (e.g., communicate policy changes to the hospital staff before the public, permit visitors at end-of-life regardless of coronavirus disease 2019 status, creating a clear definition for end-of-life) regarding restricted visitation policies.ConclusionsWe have formulated evidence-informed consensus statements regarding restricted visitation policies informed by diverse stakeholders, which could enhance patient- and family-centered care during a pandemic.
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Project description:ObjectivesTo describe the impact of coronavirus disease 2019 on family engagement among ICUs participating in a multicenter collaborative promoting implementation of family-centered care projects and to report sites' experiences with the collaborative itself prior to its cancelation due to the pandemic in March 2020.DesignCross-sectional survey.SettingTwenty-seven academic and community ICUs in the United States and South Korea.SubjectsSite leaders.InterventionsPrior to March 2020, all sites had participated in 6 months of webinars, monthly calls, and listserv communication to facilitate projects and to collect preimplementation family satisfaction and clinician perception data.Measurements and main resultsPlanned projects included ICU orientation initiatives (12, 44.4%), structured family care conferences (6, 22.2%), and ICU diaries (5, 18.5%). After cancelation of the collaborative, 22 site leaders (81.5%) were surveyed by phone from June 2020 to July 2020. Twenty (90.1%) reported having stopped their site project; projects that continued were 1) a standardized palliative extubation protocol and 2) daily written clinical summaries for families. Sites described significant variability in visitor restriction policies and uncertainty regarding future policy changes. Four sites (18.2%) reported that their hospital did not provide personal protective equipment to visitors. Regarding video conferencing with families, 11 sites (52.4%) reported clinicians' using their own personal devices. Two-hundred twelve family surveys and 346 clinician surveys collected prior to cancelation highlighted a broad need for family support. When leaders were asked on a scale from 0 to 10 how helpful collaborative activities had been prior to cancelation, mean response was 8.0 (sd 2.5).ConclusionsWhile the collaborative model can help promote ICU family engagement initiatives, coronavirus disease 2019 has impeded implementation of these initiatives even among motivated units. ICUs need adequate personal protective equipment for visitors and video conferencing capabilities on hospital devices while strict visitor restrictions continue to evolve.
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Project description: Not available
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Project description:The current coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spreading globally at an accelerated rate, with a basic reproduction number (R0) of 2-2.5, indicating that 2-3 persons will be infected from an index patient. A serious public health emergency, it is particularly deadly in vulnerable populations and communities in which healthcare providers are insufficiently prepared to manage the infection. As of March 16, 2020, there are more than 180,000 confirmed cases of COVID-19 worldwide, with more than 7000 related deaths. The SARS-CoV-2 virus has been isolated from asymptomatic individuals, and affected patients continue to be infectious 2 weeks after cessation of symptoms. The substantial morbidity and socioeconomic impact have necessitated drastic measures across all continents, including nationwide lockdowns and border closures. Pregnant women and their fetuses represent a high-risk population during infectious disease outbreaks. To date, the outcomes of 55 pregnant women infected with COVID-19 and 46 neonates have been reported in the literature, with no definite evidence of vertical transmission. Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure in the gravida. Furthermore, the pregnancy bias toward T-helper 2 (Th2) system dominance, which protects the fetus, leaves the mother vulnerable to viral infections, which are more effectively contained by the Th1 system. These unique challenges mandate an integrated approach to pregnancies affected by SARS-CoV-2. Here we present a review of COVID-19 in pregnancy, bringing together the various factors integral to the understanding of pathophysiology and susceptibility, diagnostic challenges with real-time reverse transcription polymerase chain reaction (RT-PCR) assays, therapeutic controversies, intrauterine transmission, and maternal-fetal complications. We discuss the latest options in antiviral therapy and vaccine development, including the novel use of chloroquine in the management of COVID-19. Fetal surveillance, in view of the predisposition to growth restriction and special considerations during labor and delivery, is addressed. In addition, we focus on keeping frontline obstetric care providers safe while continuing to provide essential services. Our clinical service model is built around the principles of workplace segregation, responsible social distancing, containment of cross-infection to healthcare providers, judicious use of personal protective equipment, and telemedicine. Our aim is to share a framework that can be adopted by tertiary maternity units managing pregnant women in the flux of a pandemic while maintaining the safety of the patient and healthcare provider at its core.
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Project description:OBJECTIVES:To determine mortality rates among adults with critical illness from coronavirus disease 2019. DESIGN:Observational cohort study of patients admitted from March 6, 2020, to April 17, 2020. SETTING:Six coronavirus disease 2019 designated ICUs at three hospitals within an academic health center network in Atlanta, Georgia, United States. PATIENTS:Adults greater than or equal to 18 years old with confirmed severe acute respiratory syndrome-CoV-2 disease who were admitted to an ICU during the study period. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Among 217 critically ill patients, mortality for those who required mechanical ventilation was 35.7% (59/165), with 4.8% of patients (8/165) still on the ventilator at the time of this report. Overall mortality to date in this critically ill cohort is 30.9% (67/217) and 60.4% (131/217) patients have survived to hospital discharge. Mortality was significantly associated with older age, lower body mass index, chronic renal disease, higher Sequential Organ Failure Assessment score, lower PaO2/FIO2 ratio, higher D-dimer, higher C-reactive protein, and receipt of mechanical ventilation, vasopressors, renal replacement therapy, or vasodilator therapy. CONCLUSIONS:Despite multiple reports of mortality rates exceeding 50% among critically ill adults with coronavirus disease 2019, particularly among those requiring mechanical ventilation, our early experience indicates that many patients survive their critical illness.
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Project description:BackgroundThe purpose of this study was to: 1) examine the maintenance of Physical Education and physical activity during the distance learning time, 2) determine the resources educators are utilizing to deliver PE curricula, and 3) understand the challenges experienced by educators during distance learning.MethodsA survey was sent to a cohort of school-based fitness assessment software users. Respondents were largely school-based individuals including PE teachers (n = 1789), school (n = 62) and district administrators (n = 64), nurses (n = 3), and "other" (n = 522).ResultsOf 2440 respondents, most were from a city or suburb (69.7%), elementary or middle school (72.3%), and had Title 1 status (60.4%), an indicator of low socioeconomic status. Most campuses were closed during the COVID-19 pandemic (97.8%). Of the schools closed during the pandemic, only 2.8% had no prior PE requirements and that increased to 21% during the pandemic. In schools that remained open during the pandemic, 7.7% had no prior PE requirements and this increased to 60.5%. Importantly, 79% of respondents reported that students were either "significantly less" or "somewhat less" physically active during the closure. For closed schools, the most frequently cited challenges included "student access to online learning", "teacher/student communication" and "teacher remote work arrangements". For open schools, the most commonly reported challenges included "social distancing", "access to gymnasium/equipment", and "concern for personal health and wellbeing".ConclusionThe COVID-19 pandemic has caused important reductions in PE requirements and time engaged in physical activity. Challenges experienced by teachers were identified for closed and open schools.
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