Coronavirus in Context: How Hospitals Will Prepare for Surge of COVID-19 Cases

Hello. I'm Dr. John Whyte, and welcome to Coronavirus in Context. We're going to talk today about surge capacity, and my guest is Dr. Lewis Kaplan. He's professor of surgery at the hospital at the University of Pennsylvania, and he is president of the Society of Critical Care Medicine, which recently put out a report about the resource availability of ICU beds. Dr. Kaplan, thanks for joining me.

Thank you very much for inviting me.

What are you hearing from your members about the situation of ICU beds in our hospitals?

Everyone is concerned. Everyone has set up incident command centers. Everyone is figuring out which beds can be potentially converted to ICU beds, which patients can be moved out of the hospitals, how they can augment their staff, and how they can best utilize the resources they have to take care of patients who are already in the hospital, those who may present for urgent or emergent care, all while preparing for those who will have suspected or proven COVID-19 disease.

And they're doing this in the context of keeping health care workers safe at the same time. It is a large task, but it cuts across many different service lines and brings people together in a way that perhaps nothing else has done before.

Now every hospital doesn't have critical care beds. Is that right? When you look across the country, are they tend to be localized to certain areas, whether it's urban areas or around the coast? What's kind of the overall situation of the availability of critical care beds?

SCCM has looked at this, as you know, in large part. And it has used the AHA database. When you look at where our ICU beds are clustered, they are mostly in metropolitan cities. Big cities where you would expect to find quaternary and tertiary care centers. That's also or the intensivists happened to be.

This doesn't mean that ICU beds are only in large metropolitan areas. There are certainly ICU beds outside of those spaces. And there are people who are not intensivists, not specifically trained in critical care medicine, who are looking after patients in all of those places. They could be hospitalists, or anesthesiologists, or pulmonologists. Sometimes it's even your family medical doctor serving in that capacity.

And you talked about converting beds as well. So a hospital, correct, may not have ICU beds now as we define them. But is it pretty easy to convert resources to that high-level acuity?

There are a couple of pieces to that, and the question is very germane. In general, your bed needs to be licensed to function like an ICU bed. My understanding is that some federal regulations around that will be relaxed to allow you to convert a, let's say, a post-anesthesia care unit bed or even your operating room into a de facto ICU.

The struggle that hospitals will have and that they're addressing now is, how do you get all of the supplies, and the medications, or radiology to those places that are already wired to do the kind of monitoring that you would find in an ICU if you now need to use that bed for someone that has COVID-19 disease?

Are those needs different for a patient with COVID-19 then they might be post-anesthesia, or general respiratory disease? Are you seeing a different level of acuity?

There are subtle differences. And principally -- I'll tell you, the South Koreans did this really, really well. They have an abundance of negative pressure rooms.

We'd like to put everyone in a negative pressure room. We don't have enough room to do that. So when you look at COVID-19 patients, one of the things that stands out is cardiomyopathy that generally tends not to accompany viral pneumonia. Do you need a different monitor system for that? Not really. But perhaps you need more ultrasound to look at that. So you could care for a COVID-19 patient in a non-traditional ICU setting because their needs are very, very similar.

Now what about pediatric beds and neonatal beds? We know that in terms of very young children, COVID-19 does not seem to be as aggressive or serious. It's a little different in youth. But what should we be thinking about it in terms of those pediatric beds and those neonatal beds which we know are limited in quantity?

I'll tell you, there are a lot of different ways to think about this. But I would like to suggest something that's even more different. When you look at pediatric ICUs, many of them look after people that we could consider to care for in an adult bed. And it may be that as we stand up new ICUs in nontraditional spaces and we need intensivists, some of those pediatric intensivists may be able to help augment the intensivist work force because they look after 16- to 21-year-olds, or even older people that have congenital disease. So I think this is a workforce that we have not thought about tapping, and we may be well advised to do just that.

Now let's talk about cancellation of elective surgeries. We're hearing a lot about that. Some patients are concerned about what they may consider elective versus their doctor. But can you explain to the audience, why does that help? Why does it matter if I cancel a gallbladder in the setting of COVID-19 preparedness?

Now I'm a surgeon, so I like to be in the operating room. And I'd like to think about this really as rescheduling rather than canceling, because we will get to take care of those patients. But right now, if you are reasonably healthy, you don't have much in the way of symptoms, you don't have a lot in the way of system comorbidities -- not a lot of medical conditions -- the space that you will need in the operating room must come with an anesthesiologist and/or a CRNA and a nurse.

And you must have a bed for procedures that will require inpatient stay. That becomes critical. It becomes very important as we think about how to look after people who will come in with suspected COVID-19 disease, as well as people presenting for urgent or emergent care.

If we can impose upon you and get you to help us by postponing that truly elective surgery, it incredibly helps with that capacity. And very importantly, can free up the anesthesia ventilator and the anesthesiologist and/or CRNA who know exactly how to work that device. It is a little different than the ICU ventilator, so that when we have lots of people who have COVID-19-related lung disease, we hope we don't have them all at once.

Yes.

With all the public health measures that are in place. But part of helping with staffing and bed capacity means we need your bed.

Yeah. But why are these ventilators different? How are they different?

So the knobology is a little bit different than the traditional ICU ventilator, even the advanced ICU ventilator. And the anesthesia machine has a certain capability that the ICU machine does not. Its use for passing anesthetic gases. And therefore, some of the management of that device needs to have unique filters, and you need to have a scavenging system.

So it's not exactly plug and play in the way that you might desire, and there is some specialized knowledge that is required. Just this morning, I met with the president of the American Society of Anesthesiologists. And we've asked their critical care group to work with the critical care group at SCCM, also comprised of anesthesiologists, specifically to help create some educational material for how to take an anesthesia ventilator and use it as an ICU ventilator.

Even the respiratory therapists who are absolutely key in helping us manage ventilators in the ICU and anywhere else in the hospital -- this is not what they typically do. There are some unique things, and we'll need to help them get up to speed as well.

And then how concerned are you about lack of ventilators? We're hearing about that. Is this a, you know, perhaps solution to this shortage?

It's part of that solution. We are worried. If everyone who will ever need invasive mechanical ventilation as opposed to non-invasive showed up all on the same week, well, we would be short, even including the national secure stockpile for ventilators. So the public health measures are key. They are very essential. And we would rather plan for what to do if we were overwhelmed and then not be overwhelmed at all then to have to play catch-up.

And you mentioned these negative pressure rooms earlier. And a lot of listeners may not fully understand what kind of room that is. What exactly does that mean, and why is that important for COVID-19?

It's a special room. And what that room does, it ensures that all of the airflow that enters that room only enters into the room. It does not flow back out, hence creating a negative pressure, or a draw in terms of airflow. For diseases that have an aerosolization capacity that can be spread through the air -- sneezing, coughing, procedures that involves the airway -- it is really important to make sure that if it gets into the air, it only gets out of that room through a very specialized, high-efficiency filter that is designed to trap those kinds of particles so they do not recirculate. It makes it much safer for everyone.

Yeah. You and the society have been talking about staffing needs. You referenced it earlier how many people really are involved in an ICU bed or critical care bed. Where do you see the staff deficiencies right now in terms of being able to handle a surge?

If you think about the question you asked earlier, where are the beds? Well, the beds or in the major metropolitan areas. Almost four-fold more ICU beds in those spaces than outside. That is also where you find the intensivists.

So you can imagine staffing shortages for people with very specialized training in critical care. But at the same time, you can think about shortages in respiratory therapists who help run the ventilators.

And if you think about what happens for nurses, this becomes very, very important. You are used to having a 12-hour shift for a nurse. Now if you need to, spend all of that time in personal protective equipment, it's hot. It can be bulky. It can even be a little bit hard to breathe through it. And you're up close and personal with someone with a highly transmissible disease. And you're doing things that keep you inches away. You need to be very careful with what you put on, and what you take off, and how you do that. And it might be that the nursing shift needs to be shortened so that everyone can stay absolutely focused on what they need to do to keep themselves safe while they're taking care of patients. So it will depend upon the rate at which people present symptoms.

And Dr. Kaplan, how prepared are we today for a potential surge in patients?

Cognitively, we're doing pretty well. We've thought about many different contingencies and how we would adjust care. I think that we are worried about not having enough mechanical ventilators or non-invasive ventilators. And there's a lot of focus on not having enough personal protective equipment.

You probably have seen the plea from the AMA to increase production and distribution of personal protective equipment. That has been a huge focus. I'd like to see that augmented to support our preparedness.

But one of the things that SCCM has identified is that if we need to press other individuals who don't typically work into an ICU into that space, we need to help get them up to speed. We've released free materials to help intensivists in different spaces, even within a total health care system, get all of the people who don't work into an ICU educated to help care in that kind of a world.

Well, Dr. Kaplan, I want to thank you. I want to thank the Society for Critical Care Medicine for all that you're doing to help with preparedness. For further questions, they can go to the society's website, and they can also come to Web MD. Thank you for watching.