Battling COVID-19: critical care and peri-operative healthcare resource management strategies in a tertiary academic medical centre in Singapore

Abstract

In December 2019, a cluster of atypical pneumonia cases were reported in Wuhan, China, and a novel coronavirus elucidated as the aetiologic agent. Although most initial cases occurred in China, the disease, termed coronavirus disease 2019, has become a pandemic and continues to spread rapidly with human-to-human transmission in many countries. This is the third novel coronavirus outbreak in the last two decades and presents an ensuing healthcare resource burden that threatens to overwhelm available healthcare resources. A study of the initial Chinese response has shown that there is a significant positive association between coronavirus disease 2019 mortality and healthcare resource burden. Based on the Chinese experience, some 19% of coronavirus disease 2019 cases develop severe or critical disease. This results in a need for adequate preparation and mobilisation of critical care resources to anticipate and adapt to a surge in coronavirus disease 2019 case-load in order to mitigate morbidity and mortality. In this article, we discuss some of the peri-operative and critical care resource planning considerations and management strategies employed in a tertiary academic medical centre in Singapore in response to the coronavirus disease 2019 outbreak.

Keywords: COVID-19; critical care; healthcare; peri-operative; resource management.

Figure 1

Reduction of daily total (solid line), elective (dots and dashes) and emergency (dotted line) surgical case‐load in relation to number of admitted (blue bars) and cumulative total (teal bars) coronavirus disease 2019 patients. Elective surgeries are not performed on weekends and national holidays, which have been omitted from the x‐axis. () Total surgeries; ()Elective surgeries; ()Emergency surgeries; () Admitted COVID‐19 patients; ()Cumulative total COVID‐19 patients.

Figure 2

Pandemic expansion schematic for generation of critical care bed space, involving expansion of the cohort intensive care unit into three other adjacent units, with decanting of the high dependency units into the repurposed ambulatory surgical complex. Bed numbers are indicated at the lower right of each unit, representing a total of 176 critical care beds. Each arrow represents activation of the next tier, triggered at 80% capacity of the previous tier. OR, operating room; PACU, post‐anaesthesia care unit.

Figure 3

Tiered generation of additional total critical care unit bed space (shaded bars) compared to pre‐crisis levels. Changes in the proportion of clean intensive care unit (ICU) (dotted bars), cohort ICU (striped bars) and expanded clean High dependency units (checked bars) beds are demonstrated according to according to implementation phase. Abbreviations: ambulatory surgical complex (ASC). () total critical care unit bed space; ()clean ICU bed space; () cohort ICU bed space; () expanded clean HDU bed space.

Figure 4

Predicted generation of additional critical care unit bed space (dotted area), compared to pre‐crisis baseline (shaded areas), based on the conversion of the ambulatory surgical complex into a high dependency unit for decanted patients. Additional facilities (striped areas) that may be utilised include re‐purposing suitable ward isolation rooms, elective operating rooms and post‐anaesthetic recovery areas as the pandemic progresses. () pre‐crisis baseline; ()additional critical care unit bed space; () additional facilities that may be utilised.

Figure 5

Current pre‐crisis (solid fill) and projected increase (dotted fill) physician manpower for additional critical care areas, assuming maintenance of patient care. () pre‐crisis physician manpower; ()projected physician manpower.

Figure 6

Current pre‐crisis (solid fill) and projected increase (dotted fill) nursing manpower for additional critical care areas, assuming maintenance of patient care. () pre‐crisis nursing manpower; () projected nursing manpower.