Contribution of certified registered nurse anaesthetists to the management of the COVID-19 pandemic health crisis.

Dear Editor,

Coronavirus disease 2019 (COVID-19), a new respiratory disease, is spreading globally and was declared a pandemic on March 11, 2020. As early as December 2019, COVID-19 was reported in China. On January 24, 2020, France reported its first case and the disease subsequently severely affected the Grand Est and the Paris region. According to the French Public Health Agency, as of April 26th, 124,575 people are currently affected by the COVID-19 pandemic, of which 4,682 are in intensive care units, and over 22,856 have already died (French Public Health Agency, 2020). This health crisis has highlighted a long-standing issue: the need in having more paramedic staff in general and in this context, nursing staff with high technical skills and expertise in management of life-threatening conditions and resuscitation. Indeed, the urgency is to reinforce and increase the staffing in intensive care units (ICU).

At that time, surgical activity had drastically decreased due to the confinement imposed by the President. Many operating theatres no longer needed to be kept open, or only for a few rare surgical emergencies, as unscheduled trauma activity had significantly decreased due to confinement. As a result, conventional units were converted into ICUs. Moreover, the operating theatres were also transformed into ICUs. This redeployment, which requires draconian logistical organisation, seemed less difficult than the deployment of skilled nurses. While additional rooms could be opened to receive the severely and at times critically ill, finding the nurses who would take care of the intubated, ventilated and sedated patients became a problem.

The surgical nurses working in the converted unit do not have to the necessary expertise and training to be intensivist nurses. Working in ICU requires technical skills and knowledge different from those required in working in a traditional care unit. Conventionally, to work in ICU, one must have acquired a certain amount of professional experience, expertise, and dexterity in carrying out technical care. In France, newly graduated nurses will not be chosen to be in the frontline. It is preferred that they acquire an experience before taking charge these so-called “complex” patients for whom paramedical staff are standardized. In adult ICU, article D6124-32 of the French Public Health Code indicates that a minimum of two nurses are required for every five patients and one nurse's assistant for every four patients, regardless of whether they work during the day or during the night. Patients infected with COVID-19 require more care than the majority of patients usually present in ICUs. It is recommended to have one nurse for every two COVID-19 patients. More than ever, intensivist nurses are needed.

Due to their skills, certified registered nurse anaesthetists (CRNAs) represent a solution that has been applied in the French hospitals. CRNAs are advanced-practice registered nurses who have completed a Master's of Science in Nursing. In France, nurses with at least two years of professional experience after having completed an accredited nursing program, can take the competitive exam to become CRNAs. The vast majority of CRNAs worked previously in intensive care units. Furthermore, during their advanced-degree two-year program, CRNAs have acquired all the skills required to provide specific care and technical procedures in the fields of intensive care anaesthesia, emergency medicine and pain management. They are consequently able to manage COVID-19 infected patients, especially intubated, ventilated and sedated patients in the additional and temporary ICUs.

In addition, within the EMS, CRNAs perform transfers of COVID-19 infected patients from the emergency departments of saturated hospitals to these intensive care units. The majority of patients are transferred to ICU due to severe acute hypoxaemic respiratory failure that required respiratory support (Grasselli et al, 2020). As quoted by the European Society of Anesthesiology, ‘the choice of supplementary oxygen delivery interface and the decision to provide mechanical ventilation is crucial’ (European Society of Anesthesiology, 2020). This oxygen therapy support includes oxygenation with low flow and high-flow systems, noninvasive ventilation, and intubation with mechanical ventilation. These very hypoxaemic patients may deteriorate within a few hours with the need to escalate oxygen requirements. Many patients will require rapid sequence induction and intubation to be performed quickly. Intubation should be performed by an experienced provider, as long delay and multiple attempts increase the spread of the virus and expose the patient to the risk of respiratory arrest. CRNAs’ adaptability, resilience, expertise in anesthesia, resuscitation, and their mastery of airway and difficult intubation management have made it possible to provide additional safety during prehospital intubations and ventilation, and in managing sedation if necessary. This valuable resource has allowed us to accommodate a greater number of patients and to respond in a very short time to this urgent and unexpected public health need.