Setup of a Dedicated Coronavirus Intensive Care Unit: Logistical Aspects.

To the Editor:

Northern Italy is facing a 2019 coronavirus disease (COVID-19) outbreak[1,2]; patients are mainly minimally symptomatic but may develop acute respiratory failure requiring admission to the intensive care unit (ICU).[3] Logistics are fundamental for the safety of both healthcare professionals and ICU patients, and to limit the spread of this highly infective disease.

Once alerted to the first coronavirus case requiring admission to ICU, a section of our unit was emptied and reorganized in 2 h (fig. 1). Access to the unit was limited to the minimal number of healthcare providers and mandatory through a double filter. A “clean filter” for donning is equipped with disposable personal protective equipment (gowns, filter face respirators, visors, hair covers, gloves, boot covers[4]), mirror, chairs, scrubs, waste management material, and hand disinfectants. A “contaminated filter” for doffing is equipped with waste management material, mirror, bathroom to wash before exiting, and hand disinfectants.

Fig. 1.

Organization of the intensive coronavirus unit. In red: isolated areas where full personal protection equipment is mandatory; in yellow: contaminated filter areas; in green: clean areas. A similar smaller area is a buffer zone for suspected patients. Double black arrows with dotted line: doors, kept open; double black arrows with continuous line: doors, kept closed; double blue arrows with continuous line: glass door, permanently closed; blue dotted line: glass wall; continuous black line: walls; dotted blue line: glass wall; white rectangles: intensive care unit beds; white arrows: healthcare providers’ path to enter the unit; red arrow: patients’ path to enter the unit.

For each patient, complete monitoring (blood pressure, oxygen saturation measured by pulse oximetry, end-tidal carbon dioxide, heart rate, respiratory rate, and temperature) is available and duplicated in the “control unit,” a clean area separated by a glass wall allowing direct visualization of the patients.

A dedicated aspiration system connects the expiratory valve to wall gas aspiration; this system is also available for a helmet, which is preferred to masks for continuous positive airway pressure/noninvasive ventilation to limit the droplets’ spread.[5]

A “laboratory section” includes a dedicated ultrasound machine (images are shared through a Picture Archiving and Communication System’s connection available in the unit); disposable fiberbronchoscopes and video-laryngoscopes (fiberbronchoscopy is limited to urgent indications, in order to limit airways opening); point-of-care arterial blood gas and coagulation analyses; transport ventilator; and emergency cart with defibrillator.

The main door of the unit is opened only for the patient’s admittance and once per day for garbage evacuation, performed by fully protected professionals and followed by cleaning with sodium hypochlorite 0.1 to 0.5%.

The communication between coronavirus and control units is fundamental both for clinical management and nursing; it is facilitated by an intercom and a dedicated smartphone. All the therapy is prepared outside the coronavirus unit in order to limit the time spent in it, which is physically demanding due to limited transpiration and rebreathing. All the consumable and products needed in the coronavirus unit are provided by nurses and physicians working in the control unit and dropped off in the contaminated filter, where nurses and physicians working inside the coronavirus unit can retrieve them.

A similar smaller and separated structure (buffer zone) admits patients with suspected COVID-19 infection while waiting for results. If positive, the patient is admitted to the coronavirus unit; if negative, to the general intensive care unit.

A dedicated gurney equipped with a StarMed Ventukit helmet (Intersurgical, Italy), two oxygen bottles, bag-mask, monitor, and emergency bag for intubation and chest drain positioning is available for emergency calls in the wards for positive/suspected patients; the intensivist mandatorily wears full protection equipment before leaving the unit.

The same structure was then replicated to reach 41 dedicated intensive care unit beds in 2 weeks, for a total number of 55 COVID-19 patients admitted so far. We hope sharing such information may be of help to other intensive care units having to face similar issues.

Acknowledgments

The authors acknowledge all the healthcare professionals involved in the management of such epidemics at San Matteo Hospital, in particular Alessandro Amatu, M.D. (Anesthesia and Intensive Care, San Matteo Hospital, Pavia, Italy), Federico Visconti, M.D. (Anesthesia and Intensive Care, San Matteo Hospital, Pavia, Italy), and Raffaella Arioli, B.S.N. (Anesthesia and Intensive Care, San Matteo Hospital, Pavia, Italy) for the active contribution to the setup of the unit in emergency situations.

Research Support

Support was provided solely from institutional and/or departmental sources.

Competing Interests

Dr. Mojoli received fees for lectures from GE Healthcare (Chicago, Illinois), Hamilton Medical (Bonaduz, Switzerland), and SEDA SpA (Milan, Italy). Dr. Mongodi received fees for lectures from GE Healthcare. Dr. Iotti received fees for lectures by Hamilton Medical, Eurosets (Medolla, Italy), Getinge (Gothenburg, Sweden), Intersurgical SpA (Modena, Italy), Burke & Burke SpA (Assago, Italy). A research agreement is active between the University of Pavia and Hamilton Medical. The other authors declare no competing interests.