Making critical adjustments to meet the demands of COVID-19

As ongoing waves of the COVID-19 pandemic resulted in growing numbers of critically ill patients, the Misericordia Community Hospital team responded by moving the intensive care unit (ICU) not once, but twice, to a bigger space.

“It’s a huge project,” says Kristine Kautz, unit manager of the ICU. “The timing of everything is very challenging, and you’re moving incredibly sick people around the hospital. You’ve put them on a portable ventilator to move them. They have a ton of equipment — the bed, the ventilator, the pumps, the transport monitors — and then all the people required to do that safely.”

The sickest of patients are in the ICU, and the demand for more beds grew quickly during the pandemic, seeing the original space of six beds rise to its current 22. In both moves, work included finding a large enough unit, ordering additional equipment and determining changes required for the temporary unit to ensure teams could care for fragile patients. Moving the ICU patients was one of the biggest challenges, says registered nurse Stephanie Ellis, who led the project planning for both moves.

“It is significant,” says Stephanie, program manager for medicine at the hospital.

“Each patient is ventilated and requires an entire team to move them, and you have to have your crash carts and teams ready,” she says.

“The difference from a regular bed on a medicine or surgical ward to an ICU is night and day with the volume of equipment and needs they have.”

Hospitals do not have an abundance of empty beds or units, so the growing number of critically ill COVID-19 patients resulted in the Misericordia ICU moving in November 2020 and again in late September 2021. In addition to requiring a team of about five — four nurses and a respiratory therapist — to transfer each patient, the work required significant collaboration since other patients were moved to make space to accommodate an expanding ICU.

Prior to the pandemic, the Misericordia hospital’s six-bed ICU included an additional four high-intensity beds for patients who were not sick enough to require intensive care but were too ill to move to a medicine or surgical unit. When the ICU moved into the coronary care unit in November 2020, team members increased their ability to care for 17 patients to accommodate the rise in COVID-19 numbers. This required some patients to be doubled in a single patient room. Then in September, the fourth wave hit, and the call came again to increase the ICU capacity, this time to 22 beds with up to four patients in some rooms.

“We brainstormed a lot of different ideas, and there was no perfect place. We have done very well,” says Dr. Clint Torok-Both, interim medical director of the ICU.

“In the ICU, collaboration and teamwork are very important all the time.”

“These are complex patients with a lot of nuances. We appreciate everyone’s input, and I think even more so when you’re stretched thin. Everyone has really come together and supported each other, and there’s no way we could have done it without that team.”

One of the options was to divide the ICU patients between two different units. “We figured this would be a last resort because one of the major problems with that is you end up with your team spread out all over the place and fragmented, and then if you need extra support, it’s hard to find,” says Clint. “We tried to keep everyone together so that we could continue to support each other, and I think that’s a positive.”

To accommodate the latest growth needs, the team moved into a unit divided into two hallways. The lack of an advanced computerized system meant nurses needed to watch monitors through glass windows outside patient rooms while performing other care tasks, such as charting. Electricians were brought in to increase the power load to the area to support all the ICU equipment.

Patients who were in the area at the time were moved to other areas, including a revamped dining area, which allowed an 18-bed medicine unit to grow to 27. The coronary care unit moved back to its original space on the third floor, and some medicine patients are now in the original ICU location. Every move required multiple department support, including pharmacy and food services to adjust where medicine and meals were sent.

Both moves saw the ICU patient transfers completed in one day.

“We pretty well have used every potential space that we can put a patient safely into. We have done that,” says Stephanie. “It’s what we’ve had to do to keep our patients at the forefront and as safe as we can.”

Despite the increase in beds, there has not been an increase in ICU nurses, says Kristine. Nurses redeployed from other areas in the hospital are able to assist, but critical care tasks are still performed by an ICU nurse. “This requires the ICU staff to care for one to three patients for a 12-hour period,” she says. Prior to COVID-19, care was one to one.

Caring for increasing numbers of critically ill patients has taken a toll on teams, says Clint.

“The nursing staff and the respiratory therapists have been doing an incredible job. This has been stressful on everybody, but the lion’s share does fall onto them during a respiratory pandemic to look after all of these patients,” says Clint.

“I think they have done an excellent job. They’ve managed to save a lot of lives that might not have been saved had we not been able to surge the way we did.”

Across the hospital, teams have come together to support patients and each other.

“I strongly feel that our entire team has really banded together,” says Stephanie. “You really see the mission, vision and values of Covenant shining through as they move forward each day and keep that focus on the patient and doing what we do every day for them. Despite being exhausted and despite seeing more patients, they’re doing it every day with their heart on their sleeve, doing what’s best for the patients.”

While COVID-19 numbers are beginning to trend downwards, healthcare teams are still facing stressful demands. On this particular day, there were 18 patients in the ICU unit at the Misericordia hospital. And the team is bracing for what may come once COVID-19 is finally controlled, says Clint.

“There are a lot of patients with non-COVID-19 medical problems that have had difficulty accessing care,” he says. “There are a lot of problems with substance abuse circulating in the community right now. We’re starting to see more and more of those, so as COVID-19 falls, we may start to see other patients replacing those who are in our ICUs right now.”