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 Table of Contents  
SHORT COMMUNICATION
Year : 2020  |  Volume : 4  |  Issue : 5  |  Page : 40-42

Reengineering Workflow in the Intensive Care Units during COVID-19 Pandemic


1 Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Department of Medicine/Critical Care, College of Medicine, King Khalid University, Abha, Saudi Arabia
3 Critical Care Service Administration, King Fahad Medical City, Riyadh, Saudi Arabia

Date of Submission30-Aug-2020
Date of Acceptance29-Sep-2020
Date of Web Publication7-Dec-2020

Correspondence Address:
Hasan M Al-Dorzi
ICU2, Mail Code 1425, PO Box: 22490, Riyadh 11426
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_39_20

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  Abstract 


Coronavirus disease-2019 (COVID-19) has led to a pandemic that pushed many intensive care units (ICUs) worldwide beyond their limits. To maintain efficient critical care services and to protect critical care staff, reengineering the ICU workflow became a necessity. The care of COVID-19 patients occurred in designated ICUs. High-efficiency particulate air filters were installed in rooms that did not have negative pressure. Non-ICU wards were used for care of critically ill patients. Handover between physicians, multidisciplinary rounds, and entry into the ICU were changed to avoid large gathering inside the units. Tiered staffing approach was used to maintain an adequate nurse-to-patient ratio. The care of non-COVID-19 patients took place in clean ICUs by a dedicated medical team to avoid cross contamination. As visitation was prohibited during the pandemic, communication with families of patients was done via advanced telecommunication methods such as videoconferencing. To protect ICU staff, appropriate donning and doffing of personal protective equipment were monitored and corrected by qualified personnel. Reuse or extended use of such equipment was carried out due to supply shortage.

Keywords: COVID-19, intensive care, severe acute respiratory syndrome coronavirus-2, workflow


How to cite this article:
Al-Dorzi HM, Al Bshabshe A, Sakkijha H. Reengineering Workflow in the Intensive Care Units during COVID-19 Pandemic. Saudi Crit Care J 2020;4, Suppl S1:40-2

How to cite this URL:
Al-Dorzi HM, Al Bshabshe A, Sakkijha H. Reengineering Workflow in the Intensive Care Units during COVID-19 Pandemic. Saudi Crit Care J [serial online] 2020 [cited 2021 Jul 27];4, Suppl S1:40-2. Available from: https://www.sccj-sa.org/text.asp?2020/4/5/40/302579




  Introduction Top


Coronavirus disease 2019 (COVID-19), which is caused by a novel coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]), has led to a pandemic resulting in 21,294,845 cases and 761,779 fatalities (6.0%) worldwide as of August 16, 2020.[1] In Saudi Arabia, which was affected like many other countries, there were 297,315 confirmed cases with 3369 deaths (1.1%).[1] The virus may lead to severe pneumonia, acute respiratory distress syndrome (17%–29%), and critical illness (23%–32%) among hospitalized patients.[2],[3],[4],[5] Hence, the pandemic has caused a high demand for medical care in hospitals and acute-care facilities; consequently, many health-care systems were strained worldwide.[6] Preparation for the pandemic in its worst forms was a daily real-life task for health-care systems to face the pandemic in a highly effective way. The model of workflow in the intensive care unit (ICU) is usually well structured and can be shaped in a clearly defined frame, yet it is flexible enough so it can be adopted by most units. Nevertheless, the COVID-19 pandemic has challenged ICUs worldwide including the ones in Saudi Arabia. To continue providing effective care during the pandemic, reengineering of the flow of care in the different ICUs was needed. The main goals of this flow reengineering were providing care to the large of number of COVID-19 patients while maintaining infection prevention and control, taking into consideration the limitation in space and shortage in needed supplies, maintaining the care to critically ill patients who did not have COVID-19, and protection of ICU staff.


  Reengineering Intensive Care Unit Flow to Care for Patients with COVID-19 Top


The rapid identification and proper isolation of suspected/confirmed cases were crucial and mandated changes in the way we initially evaluated patients at the start of their journey in the hospital. The high number of affected patients requiring care in the ICU necessitated increasing the capacity to take care of patients ideally in single negative-pressure airborne isolation rooms. As this was not feasible in many ICUs, high-efficiency particulate air filters were installed in single rooms. Cohorting COVID-19 patients in shared rooms or open ICU bays was an alternative option for other ICUs, while transforming regular wards into ICU rooms was done by others to augment ICU capacity. The participation of noncritical care practitioners and nurses in ICU care during the high-demand periods was inevitable. By using the tiered staffing model,[7] these health-care workers were supervised by critical care providers (i. e., a critical care nurse supervising two noncritical care nurses) to ensure the implementation of critical care processes up to the ICU care standards. This helped to maintain the needed nurse-to-patient ratio. To use ICU resources more effectively, timely discharge to step-down units was critical. Visitation by family members was prohibited/limited. This required changes in the way consents were obtained and in how communication with family members was undertaken. Advanced telecommunication methods, such as videoconferencing, were used for these purposes. Other implemented changes in the workflow for COVID patients are described in [Table 1].
Table 1: Key strategic changes in intensive care units workflow during the coronavirus disease-2019 pandemic

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  Reengineering Intensive Care Unit Workflow to care for Patients without COVID-19 Top


The lockdown associated with the pandemic changed the profiles of patients admitted to the hospital.[8] For example, most elective surgeries were postponed during the pandemic, resulting in surgical ICU admissions mostly after emergency procedures. Establishment of an effective system that allowed nonCOVID-19 patients to receive appropriate medical care was important. These patients were managed in clean ICUs and the treating ICU team did not manage COVID-19 patients to avoid cross-contamination. However, some patients admitted to the clean ICUs turned out to have COVID-19 as they were admitted during the SARS-CoV-2 incubation period or when they had mild symptoms that were not picked up on triage. Hence, screening for SARS-CoV-2 using reverse transcriptase–polymerase chain reaction became a routine practice for all patients. When feasible, new patients requiring ICU care with pending SARS-CoV-2 test results were dealt with as positive cases until the test results became available. Other suggested/ implemented changes in the workflow for non-COVID patients are described in [Table 1].


  Reengineering Intensive Care Unit Workflow to Protect Health-care Providers Top


Health-care workers were at high risk of acquiring COVID-19 due to the higher exposure dose from aerosol-generating procedures and longer periods of patient contact. Strict adherence to droplet and contact precautions including hand hygiene, eye protection, and safe donning and doffing of personal protective equipment were the main defenses against the transmission of SARS-CoV-2. Empowering infection control officers or trained ICU staff to monitor and correct personal protective equipment practices was important. Fit-tested N95 respirators were used by health-care workers while caring for patients with COVID-19. Powered air-purifying respirators were alternatives for N95 respirators for workers who were not fit tested or failed fit testing. Otherwise, surgical mask application in clinical areas was a universal practice. Careful use of personal protective equipment was helpful to conserve supplies required for infection control. Extended use and re-use of N95 respirators were implemented with appropriate precautions.[9] Additional needed changes to protect health-care workers included minimizing unnecessary exposure, (for example, the adjustment of the ventilator settings from outside the patients’ rooms and the use of long tubes to administer intravenous medications without the need to enter the room) and implementing telemedicine. The psychological aspect of ICU staff was addressed and appropriate psychological support was provided.[10],[11] Other related changes are described in [Table 1].


  Conclusions Top


Proper planning was the key to the successful management of the COVID-19 pandemic. As this pandemic resulted in a high number of critically ill patients beyond the regular ICU capacity, workflow in the ICU had to be reengineered to get the maximum benefit and to mitigate the probable harms. Although ICU workflow reengineering might have varied from one unit to another based on the available space and resources, it involved COVID-19 patients as well as other critically patients. Protection of staff was equally important, especially with limited supplies of personal protective equipment. Communication of workflow adaptations to all clinical teams and ancillary services was a must to guarantee full engagement and implementation of the change in a smooth manner that led to efficient patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Coronavirus Disease 2019 COVID-19): Situation Report, 209; 2020. [Last accessed on 2020 Aug 22].  Back to cited text no. 1
    
2.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
    
3.
Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. Lancet Respir Med 2020;8:475-81.  Back to cited text no. 3
    
4.
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.  Back to cited text no. 4
    
5.
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.  Back to cited text no. 5
    
6.
Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: Early experience and forecast during an emergency response. JAMA 2020;323:1545-6.  Back to cited text no. 6
    
7.
Harris GH, Baldisseri MR, Reynolds BR, Orsino AS, Sackrowitz R, Bishop JM. Design for implementation of a system-level ICU pandemic surge staffing plan. Crit Care Explor 2020;2:e0136.  Back to cited text no. 7
    
8.
Marijon E, Karam N, Jost D, Perrot D, Frattini B, Derkenne C, et al. Out-of-hospital cardiac arrest during the COVID-19 pandemic in Paris, France: A population-based, observational study. Lancet Public Health 2020;5:e437-43.  Back to cited text no. 8
    
9.
Centers for Disease Control and Prevention. Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings. Available from: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html. [Last accessed on 2020 Jun 08].  Back to cited text no. 9
    
10.
Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study. Brain Behav Immun 2020;87:11-7.  Back to cited text no. 10
    
11.
Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 2020;173:317-20.  Back to cited text no. 11
    



 
 
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