Coronavirus disease 2019: Challenges and practical solutions in the intensive care unit

Dear editor

Since the discovery of severe acute respiratory syndrome coronavirus 2, coronavirus disease 2019 (COVID-19) has rapidly progressed into a pandemic. We outline challenges in managing and preparing for a surge of critically ill COVID-19 patients, adapting solutions from international guidelines.

Ten challenges and practical solutions

1. Setting up frontline intensive care unit teams

A key priority of our pandemic response was to set up frontline COVID-19 intensive care unit (ICU) teams rapidly. ¹ Junior residents and nurses with critical-care experience were deployed from various departments and ICUs to support these intensivist-led teams. ²

2. Designating an isolation ICU

Negative-pressure airborne infection isolation rooms (AIIR) with critical-care requisite infrastructure were designated as the isolation ICU to segregate resources and allow environmental and engineering controls to be applied. ³ Rapid testing for COVID-19 facilitated timely de-isolation and patient decantment to create capacity. ²

3. Implementing strict infection control in the ICU

Contact and droplet precautions were employed in the ICU, and National Institute for Occupational Safety and Health–certified N95 particulate respirators or powered air-purifying respirators were used during aerosol-generating procedures such as intubation. ³ Training on infection-control measures, including donning and doffing of personal protective equipment (PPE), was conducted, and visual prompts such as posters were installed. Protocols for intubation, cardiac arrest and transport were adapted to maintain infection control. ¹ For example, high-efficiency particulate air (HEPA) filters were used with manual resuscitator and ventilator expiratory ports.

4. Maintaining clinical standards and adapting clinical workflows

Low tidal volume ventilation, fluid-restrictive strategies and personalised positive end expiratory pressure titration were used in the management of COVID-19 acute respiratory distress syndrome. ⁴ Early prone ventilation was employed. High-flow nasal cannula may be considered. However, close monitoring and a low threshold for intubation is emphasised.^1,4

5. Maintaining access to sub-speciality care

Isolation ward rosters for various medical, surgical, interventional and imaging sub-specialty and allied health services were created to ensure service continuity. ¹ Teleconsultation was utilised whenever possible.

6. Adapting cardiac arrest (Code Blue) and rapid response services

Isolation ICU teams provided rapid response and Code Blue services for isolated general ward patients. PPE, HEPA filters and hand-held video laryngoscopes were incorporated into existing resuscitation kits. ¹

7. Maintaining communication with families

Stringent infection-control precautions precluded any visitors in the ICU. Families were engaged via regular updates, and special arrangements were made for video calls if appropriate. ⁵ Palliative medicine services and medical social workers provided additional psychosocial support.

8. Protecting physical and mental health of health-care workers

Special attention should be dedicated to the protection of health-care workers (HCWs), including infection-control education, ensuring safe use and adequate supply of PPE. Mental-health support peer networks and hotlines were created, and daily situation updates were communicated by senior management to ensure staff engagement. ² HCWs were instructed to seek medical attention at staff clinics if unwell. Temperature surveillance and central tracking allowed mapping of emerging clusters.

9. Upskilling of HCWs

An online ICU refresher course was rapidly assembled for non-intensivists identified for surge deployment. An ICU nursing conversion course created ramped up nursing staff training. In situ interprofessional simulation training was organised. Inter-hospital ICU web conferences were also held to exchange knowledge on critical-care management.

10. ICU surge capacity planning

Finally, whilst public-health measures employed in Singapore have flattened the local pandemic curve, staying prepared for a potential surge is prudent. Alternative ICU care sites, including high dependency, post-anaesthetic care units, operating and endoscopy suites, were identified. Infrastructural capabilities, including availability of oxygen ports, water and drainage for haemodialysis, need to be considered. Expedited procurement, conservation and safe reuse strategies for consumables and drugs were employed.