As a result of the continued growth in cases of the coronavirus disease 2019 (COVID-19), many intensive care units (ICUs) have already reached or have exceeded their usual capacity. As the number of patients with COVID-19 has increased, however, hospital visits from those seeking emergent care for non-COVID-19 conditions have reportedly diminished substantially.

At one hospital in Ottawa, Canada, for example, visits to the emergency department (ED) have recently been reduced by 40% since stay-at-home orders took effect, and the chief of medicine at one hospital in New Hampshire recently reported that the number of patients seeking treatment in their ED was down by approximately one-third.1,2

As part of the public health messaging intended to reduce unnecessary use of healthcare resources for non-COVID-19 related needs, the general public has been encouraged to postpone elective surgeries. Additionally, many routine issues are now being treated via telemedicine as often as possible.

These measures may have led to a misconception that patients without COVID-19 should also avoid seeking emergent care in hospitals. Another factor likely driving the decline in ED use is patients’ fear of contracting the virus via cross-contamination. In a Gallup poll, >80% of patients with heart disease indicated that they would be “very concerned” or “moderately concerned” about exposure to the virus if they required immediate treatment at a hospital or doctor’s office.3

These findings support the concerns of many healthcare providers (HCP) that the “pandemic has produced a silent sub-epidemic of people who need care at hospitals but dare not come in,” according to a Washington Post article.3 “They include people with inflamed appendixes, infected gall bladders and bowel obstructions, and more ominously, chest pains and stroke symptoms, according to these physicians and early research.”

For instance, there was a 38% reduction in patients treated for ST-elevation myocardial infarction (STEMI) from January 1 to March 31 at 9 high-volume catheterization laboratories across the United States4, and the number of patients with stroke who were treated at the University of Miami-Jackson Memorial Comprehensive Stroke Center in Florida in March was approximately 30% lower compared with February.3

These trends have prompted physicians and hospitals to urge the public to seek immediate medical care when needed (noting the greater risk in postponing treatment for certain conditions), with reassurance regarding sound infection control practices that hospitals have implemented in light of the pandemic.1,2,5

To learn more about such measures currently being utilized in ICUs, we checked in with Pat Posa, RN, MSA, FAAN, Quality Excellence Leader at St. Joseph Mercy Hospital in Farmington, Michigan, and member of the Society for Critical Care Medicine’s ICU Liberation Committee.

With so many patients being admitted with COVID-19, what is the approach for non-COVID admissions?

Most hospital are cohorting all patients with COVID in designated units in the hospital — both ICU and non-ICU. There are fewer admissions to the hospitals because all elective procedures have been cancelled; this extra capacity has allowed hospitals to cohort effectively.

What are some of the protocols that ICUs have implemented to prevent cross-contamination to and between patients?  

There are extensive isolation practices for patients with COVID-19, which require that every person entering the room of a patient who is positive for COVID-19 or being ruled out for COVID-19 has to apply the following: gown, gloves, mask, and eye protection (can be goggles or a face shield), along with hand washing. 

The type of mask needed for patients in the non-ICU units without an aerosol generating procedure is just a regular surgical mask. In the ICU, for patients on a ventilator, a respirator or N95 mask is required. These are all recommendations from the CDC and WHO.6,7 They have defined these isolation expectations and what is considered an aerosol generating procedure.

There is a specific way the HCP needs to put on the isolation materials (donning) and a specific way and order to take the gear off (doffing) to prevent contamination. To ensure this is done properly, many hospitals have people monitoring real-time the donning and doffing process.

What protocols have been implemented to prevent cross-contamination from patients to healthcare providers?  

The isolation practices shared above prevent cross-contamination from patient to patient as well as from patient to HCPs. A number of hospitals have also put in place universal masking so that everyone entering the hospital will don a mask and wear it the entire time they are in the facility. Because it is known that you can have the virus without symptoms and be able to pass it to others, this protects the HCP and patients as well.

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Were there patients who were in ICUs before COVID-19 who are now being infected with the virus?

With the correct equipment and isolation practices, there is minimal to no cross-contamination. Also, patients with COVID-19 are commonly cohorted into the same ICU.

What have other countries’ healthcare systems done to mitigate the overtaxation of the ICUs?

The United States and other countries have implemented social distancing strategies (staying 6 feet away from any other person, handwashing, and coughing into the elbow) as well as stay-at-home orders to prevent the spread of the disease, which includes closing all nonessential businesses. Because this virus is novel, no one has immunity to it, and it is highly contagious, which is why it can and has spread so rapidly.

These mitigation strategies will prevent a rapid peak of new cases that will require hospitalization — the aim is to “flatten the curve.” The health system in the United States and around the world have a finite capacity, and with a rapid surge they can be overwhelmed. This has been seen in Italy as well as some areas in the United States, like New York City and Detroit.

Along with social distancing and stay-at-home orders, some hospitals have had to increase their capacity, especially ICU beds. So, they have stopped all elective procedures to open up more beds, and they have also converted non-ICU beds to ICU beds.

Adequate testing is also necessary to understand who has the disease so they can be isolated to prevent the spread. The availability of testing is variable between countries as well as within countries.

How will field hospitals help alleviate the ICU burden?

If the surge is not prevented, hospitals will run out of beds, so additional beds will be needed. Most hospitals have a finite footprint in their facilities and cannot create a significant number of new beds. This is where the field hospitals come into play. These field hospitals can be used to offload the hospitals, so patients can be transferred there when their illness improves but they are not quite ready to be discharged home. 

With this illness, many patients have required mechanical ventilation for an extended period of time, as well as increased sedation and pain medication. They are often too sick to get up and mobilize, so they become very debilitated. The field hospital could also be used to provide rehabilitation to these patients. Also, these facilities can admit patients with COVID-19 directly and provide the necessary care.

References

1. Payne E. Please come to see us, Ottawa hospitals ask after patients stay away for fear of COVID-19. Ottowa Citizen. April 22, 2020.

2. Ganley R, McIntyre M. N.H. doctors worried people avoiding the ER out of fear of COVID-19. New Hampshire Public Radio. April 20, 2020.

3. Bernstein L, Sellers FS. Patients with heart attacks, strokes and even appendicitis vanish from hospitals. Washington Post. April 19, 2020.

4. Garcia S, Albaghdadi MS, Perwaiz M, et al. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic [published online April 10, 2020]. J Am Coll Cardiol. doi:10.1016/j.jacc.2020.04.011

5. Fieldberg A. Doctor urges people not to avoid hospitals over COVID-19 fears if they need medical attention. CTV News Calgary. April 15, 2020.

6. Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (COVID-19) in healthcare settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Accessed on April 22, 2020.

7. World Health Organization. Guidance for health workers. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/health-workers Accessed on April 22, 2020.