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.
Infection Control
The open care setting provided unique infection control issues that had to be addressed.12 The open setting allowed preservation of PPE and the ability for bundled care to be delivered easily. The VAAAHS infection control team worked closely with the ICU team to develop practices to ensure both patient and health care worker protection. Notable challenges included donning new gowns between patients when a PAPR was already being worn, leading to draping of new gowns over existing gowns when going between patients. True hand hygiene was also difficult, as health care workers did not want to completely remove gloves while in the patient care area. Layering of 2 pairs of gloves allowed the outer gloves to be removed after care of each patient, at which time alcohol gel was applied to the inner gloves, a new gown was placed over the existing gown, and a new pair of gloves was layered on top.
Although patients were intubated for long periods in the PACU-ICU, there was concern for increased risk of exposure of health care workers after extubation given the inability to contain the coughing patients within a private room. If a patient did well, they were transferred to a private room on the general medical floors within 24 hours of extubation to minimize this risk.
Privacy
The open care design meant less privacy for patients than would be provided in a private room. Curtains were drawn around patient beds as much as possible, especially for nursing care, but priority was given to visualization of the ventilator when a HCP was not present to ensure safety at all times. The majority of patients cared for in the PACU-ICU were intubated and sedated on arrival, but thankfully many were extubated. After extubation privacy in the open care area became more of an issue and may have led to more nighttime disturbances and substandard delirium prevention measures. Priority was given to expediting the transfer of these patients to private rooms on the general medical floor once their respiratory status was deemed stable.
Conclusions
The COVID-19 pandemic is truly an unprecedented event in our nation’s history, which has led to the first nationwide authorization of the fourth mission of VA to provide support for national, state, and local public health. The PACU-ICU was designed, engineered, built, and staffed by perioperative HCPs through an exceptional multidisciplinary effort in a matter of days. Through this dedication of health care workers and staff, the VAAAHS was able to care for critically ill veterans from Southeast Michigan and serve the community during a time of overwhelming demand on the national health care system.
Acknowledgments
The authors thank the outstanding team of administrators, engineers, physical therapists, pharmacists, nurses, advanced practice providers, CRNAs, respiratory therapists, and physicians who made it possible to respond to our veterans’ and our community’s needs in a time of unprecedented demand on our health care system. A special thank you to Eric Deters, Chief Strategy Officer; Brittany McClure, ICU Nurse Manager; and Mark Dotson, Chief Supply Chain Officer. It was a privilege to serve on this mission together.
