Creating an Intensive Care Unit From a Postanesthesia Care Unit for the COVID-19 Surge at the Veterans Affairs Ann Arbor Healthcare System
Objectives: To prepare for the predicted surge of patients with COVID-19 in Southeast Michigan, the US Department of Veterans Affairs Ann Arbor Healthcare System engineered, built, and staffed a 12-bed intensive care unit (ICU) from the existing postanesthesia care unit (PACU).
Observations: Considerations including floor planning, reversal of airflow, strict airborne precautions, sealing off a dedicated nursing station, and developing an infection control plan in an open care unit. A staffing model was created that included anesthesiologist intensivists, advanced practice providers, residents, certified registered nurse anesthetists, and perioperative nurses working alongside ICU trained nurses. Challenges arose in infection control, communication, mechanical ventilation using anesthesia machines, providing renal replacement therapy, and maintaining patient privacy in an open unit.
Conclusions: This article describes the setup, challenges, and solutions that allowed the creation of the PACU-ICU to help serve veterans and civilians during a time of unprecedented strain on the health care system due to COVID-19.
Challenges and Solutions
Communication between staff located within the patient area and staff located in the nursing station was difficult given the loud noise generated by a PAPR and the plexiglass walls that separated the areas. Multiple techniques were attempted to overcome this. Dry erase boards were placed within the space to facilitate requests, but these were found to be time consuming. Two-way radios worked well if the users were wearing N95s but were harder to communicate when users were wearing PAPRs. Baby monitors were purchased to facilitate 2-way communication and were useful at times although quieter than desired. Vocera B3000N Communication Badges, which were already utilized in the perioperative period at the facility, could be utilized underneath PPE and were ultimately the best form of clear communication between staff within the patient care area and outside the negative pressure zone. In accordance with company guidance, these mobile devices were cleaned with virucidal wipes after use.10
Communication with patients’ families was critically important. The ICU team, palliative care team, or social workers made daily telephone calls to family members. The facility telehealth coordinator provided a designated tablet device to enable the intensivists to video conference with the patients’ families at bedside, utilizing virtual care manager appointments. This allowed families to see and interact with their loved ones despite the prohibition of family visitors. Every effort was made to utilize video calling daily; however, clinical demands as well as Internet and technological constraints from individual family members intermittently precluded video calls.
Clinical Challenges
Patients with severe COVID-19 infections requiring mechanical ventilation have proven to be exceptionally high-acuity patients with myriad organ-based complications reported.11 Specific to our PACU-ICU, we determined that it was impractical to arrange for continuous RRT given the amount of training PACU nursing staff would have required and the limited ICU nursing staff in the PACU-ICU. Intermittent hemodialysis required replumbing for water supply and drainage but was ultimately not required as our facility expanded the number of continuous RRT machines available, allowing all patients in the COVID-19 ICU who required RRT to stay in the 16-bed ICU. Daily communication with the MICU allowed for safe transfer of patients with imminent needs for RRT to the MICU, providing a coordinated strategy for the deployment of scarce resources across our expanded ICU footprint.
Using anesthesia machines as ICU ventilators proved challenging, despite following best practice guidance.8 Notably, anesthesia machines are not actively humidified and require very high fresh gas flows, necessitating the addition of heat moisture exchangers (HME) to the circuit. Also, viral filters were placed in the circuit to prevent machine contamination. The addition of the HME and viral filters to each circuit increased the present dead space and led todifficulty in providing adequate ventilation to patients who already may have had a high proportion of physiologic dead space. The high fresh gas flows used still seemed inadequate in preventing moisture buildup in the machine parts, necessitating frequent exchanges of viral filters, HMEs, and circuits to prevent high peak airway pressures. In addition, anesthesia machines directly sample gas from the patient's breathing circuit, creating the risk for contamination of the space. This required a reconfiguration to allow for a suction scavenging system by VAAAHS biomedical engineers. Also, anesthesia machines are not designed for long-term ventilation and have different ventilation modes compared with modern ICU ventilators. Although they were used for several patients when the PACU-ICU opened, the hospital was able to acquire additional ICU ventilators, and extensive or prolonged use of anesthesia machine ventilators was avoided.
