By Abhijit Duggal, MD, and Raed Dweik, MD, MBA
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Cleveland Clinic has 11 regional hospitals throughout Northeast Ohio, with capacity for more than 500 intensive care unit (ICU) beds. As home to pulmonary medicine, critical care and infectious disease departments, Cleveland Clinic’s Respiratory Institute coordinated this expansive network of regional ICUs and was able to design an innovative structure integrating these units for optimal resource allocation in anticipation of a surge in volume of critically ill patients during the COVID-19 pandemic.
Development of a surge plan
The initial step for the surge plan included assessing the ability of the health system to augment based on local needs across the geographic and temporal expanse of the surge. Without changing the current staffing model, the medical ICU (MICU) at Cleveland Clinic’s main campus included a total capacity of 85 beds, with ample mechanical ventilators and supplies. In addition, surge planning assessed the pre-incident capacity for the entire regional network, which under conventional conditions could accommodate 520 ICU patients. Inventories of staffing, space and supplies were compared with epidemiological predictions for the pandemic, including possible worst-case scenarios developed by Respiratory Institute experts and other groups.
The ability to rapidly expand bed capacity and mobilize resources within the hospital system allows Cleveland Clinic to immediately adapt to increased patient loads associated with disasters. The Respiratory Institute developed its own model for tiered surge capacity using four designations: “conventional,” “extension of capacity,” “contingency” and “crisis.” At main campus, these designations would allow expansion of ICU capacity by 20%, 100% and 200% respectively, taking into consideration the inventory of resources, including:
- Staffing: faculty, trainees, advanced practice providers, respiratory therapists, nurses, etc.
- Space: cohort units, expanding traditional and nontraditional bed capacity, etc.
- Supplies: personal protective equipment (PPE), mechanical ventilators, etc.
By combining and coordinating ICU resources throughout the region, the “contingency” capacity rose to 520 beds, an increase of over 500% compared to the “conventional” main campus MICU. For “crisis” levels of care, adding repurposed areas capable of providing critical care, including post-anesthesia units and nonmedical units and procedure areas with monitoring capability and high-flow oxygen outlets, the overall capacity rose by 900% to 1,053 beds throughout the region.
Standardized management of critically ill patients with COVID-19
It is essential that patients throughout Cleveland Clinic health system receive the same level of quality care. Institutional protocols for caring for patients with COVID-19 were developed and disseminated throughout the health system by multidisciplinary teams of critical care and infectious disease physicians, advanced practice providers, nurses, respiratory therapists and pharmacists.
Physicians, nurses and respiratory therapists from main campus, who routinely manage the most complex and critically ill patients in the hospital system, were systematically redeployed to smaller regional hospitals, where there was less experience performing certain aspects of critical care management. These assignments brought knowledge and confidence in infrequently used skills, such as prone positioning of patients in severe hypoxic respiratory failure.
Under the guidance of physicians from the Respiratory Institute, educational modules were developed and disseminated through Cleveland Clinic’s MyLearning platform. They addressed general topics in critical care, specifically aimed at noncritical care providers who might be redeployed during surge staffing scenarios.
Repurposing of patient care areas
During surge conditions requiring “contingency” and “crisis” responses, elective procedures could be canceled to reduce ICU utilization. Additionally, critical care could be provided in nontraditional locations, such as in the Emergency Department and procedure areas.
Nonclinical spaces also could be converted into temporary hospital bed spaces for lower acuity patients. For example, Cleveland Clinic’s Health Education Campus, a building shared by Cleveland Clinic Lerner College of Medicine and Case Western Reserve University School of Medicine for preclinical medical education, was converted into a temporary hospital with a capacity of approximately 1,000 beds, complete with newly installed oxygen and suction capability for each bed space. Although the improvised facility, named Hope Hospital, was equipped to care for patients requiring only minimal respiratory support, the facility was capable of offsetting demand on inpatient units and ICUs in other campus locations.
Cleveland Clinic is fortunate to have a large workforce of physicians, nurses, respiratory therapists, pharmacists and ancillary staff employed throughout its regional hospital network. There were several strategies for increasing the workforce for “contingency” and “crisis” care. For example, changes in usual workflow could include increasing work hours or nurse-to-patient ratios during surge conditions, similar to measures undertaken in New York City and other areas that were hit hard during the first COVID-19 surge.
Non-ICU clinicians also could help extend the capacity of ICU providers. Cleveland Clinic dedicated significant resources to educating and preparing noncritical care providers in the event that they needed to be reassigned to critical care units. Extensive educational materials were provided on the management of COVID-19 and general ICU care to help physicians and advanced practice providers prepare for possible deployment to the ICU. This initiative included nurses from bronchoscopy and other procedural areas shadowing ICU nurses, integrating fellows from noncritical care specialties onto ICU teams, and credentialing subspecialty fellows to work as internal medicine hospitalists. Other considerations during “crisis” care included an expanded role for trainees (such as critical care fellows’ working as partners alongside their attending physicians) to increase capacity.
There are possible complications related to increased work hours and expanded roles for providers. Provider burnout is an important threat to a healthcare system, especially during pandemics, when the strain on a system and its individuals can last for months. At Cleveland Clinic, several programs have been implemented to mitigate provider burnout, including peer support groups, professional counseling, alternative housing and assistance with finding childcare.
Conservation, adaptation and substitution of supplies
In addition to strains on personnel, pandemic-related patient surges would also strain the availability of technology and other supplies. Plans for increasing the number of available mechanical ventilators included reallocation of anesthesia machines as ICU ventilators and adapting a single ventilator for simultaneous use by more than one patient by using valves and fittings to split the airflow circuit. Daily inventory was taken of all ventilators and related supplies, and ventilators throughout the system were reallocated based on current and anticipated needs, guided by a committee of experts in critical care and respiratory therapy.
At the onset of the pandemic, Cleveland Clinic took a careful inventory of its PPE, including N95 masks, surgical masks, disposable gloves and gowns. There was a stockpile of N95 masks that would last a year during typical use. In accordance with guidelines from the Centers for Disease Control and Prevention (CDC), efforts were made to conserve N95 masks by restricting their use to the procedures with the highest risk of aerosolization, such as BiPAP use, bronchoscopy and endotracheal intubation. Protocols also were developed for the safe reuse of some PPE in appropriate situations.
As has often been noted, crisis situations not only bring out the best in people, but also come with a number of silver linings for those prepared to discern them. The COVID-19 pandemic, with its threatened surge in volume of critically ill patients, forced a rapid mobilization of personnel, resources and innovative ideas to meet the challenge. Many of the ideas and innovations developed during the early stages of the pandemic will continue to be used as best practices in many areas of critical care and other medical specialties. The most critical resource in the process was the people involved and their ability to follow Cleveland Clinic’s motto “to act as a unit” as they put “patients first.”