By Lucie Pelunkova, MSc, Critical Care Nursing, Nurse Educational Specialist, Neurologic Critical Care Unit, Cleveland Clinic Abu Dhabi; Nouran Salem, PharmD, BCCCP, MBA, Critical Care Pharmacotherapy Specialist, Cleveland Clinic Abu Dhabi; Seby John, MD, Consultant Neurologist, Vascular Neurology and Neurointerventional Surgery, Neurological Institute, Cleveland Clinic Abu Dhabi; Fadi Hamed, MD, Consultant Intensivist, Section Head, Medical and Surgical Critical Care Unit, Critical Care Institute, Cleveland Clinic Abu Dhabi; and Jamil R. Dibu, MD, Consultant Intensivist, Neurocritical Care, Section Head, Neurologic Critical Care Unit, Critical Care Institute, Cleveland Clinic Abu Dhabi
Severe Acute Respiratory Syndrome Coronavirus-2 is a novel coronavirus first detected in Wuhan, China in December 20191, causing a pandemic of coronavirus disease (COVID-19) that has infected more than 49 million patients worldwide with more than 1 million deaths2. In the United Arab Emirates (UAE), the first surge of COVID-19 patients occurred early April with the first peak in mid-May. To date, almost 140,000 cases with more than 500 deaths have been reported in the UAE2.
Cleveland Clinic Abu Dhabi (CCAD) COVID-19 taskforce was formed in early March to plan our response plan in line with directives of the Department of Health (DoH) who organized the pre-hospital triaging of COVID-19 patients. The taskforce’s strategy facing the surge was communicated organization-wide focusing on key elements of space, staff and stuff while optimizing resource utilization, providing continuous education, standard protocols and research adapting to the dynamic COVID-19 pandemic.
Overall, we have three 24 beds ICU specialized units: Neurologic (NCCU), Medical-Surgical (MSCCU) and Cardio-Thoracic (CTCCU). With the DoH directive to receive the sickest COVID-19 patients, we expanded our ICU beds capacity from 72 to 130 beds (80%), 82 of which were dedicated COVID-19 ICU beds.
The NCCU converted to a COVID-19 ICU, admitting patients particularly with neurological involvement. The other two COVID-19 ICU’s were the MSCCU and a regular ward of 34 beds turning into a low acuity COVID-19 ICU (eg, low dose vasopressors, recovering respiratory failure). Converting the NCCU into a COVID-19 ICU required important logistical steps: All non-essential equipment and supplies were stored outside of the ICU.
Supplies and equipment dedicated to neurocritically ill patients were duplicated for COVID-19 and non-COVID ICU’s. Constructional and interior design changes ensured separate areas for donning and doffing of personal protective equipment to prevent infection spread and all patient rooms and common areas were retrofitted to negative air pressure areas.
To maintain our neurocritical standards and quality of care, we cohorted our non-COVID ICU patients into one pod of the non-COVID high acuity ICU, while the low acuity neurocritical care patients were admitted to the Post Anesthesia Care Unit (PACU), which was transformed into a non-COVID ICU (24 beds).
Staff and Education
Consideration of alternating models of care was necessary to meet patient needs and optimize patient safety with the expansion of ICU beds3. With cancellation of elective surgeries and clinics, physicians from other institutes were re-deployed to the ICU to support the tiered-staffing model4. “ICU for the non-intensivist” webinars were broadcasted and recorded to all physicians. Our dedicated Neuro ICU physicians and nurses were split between both COVID-19 and non-COVID units to care for the cohorted neurocritically ill patients and rotate assignments to minimize exposure and avoid burnout. All nurses with previous ICU experience were re-trained, regular floor and PACU nurses upskilled and re-deployed to the low acuity ICU with guidance of senior ICU nurses.
Educational videos for our caregivers on appropriate donning and doffing to remain safe were played in loop at both dedicated locations for donning and doffing in conjunction with practice sessions. In addition, trained groups of caregivers observed and audited donning and doffing of caregivers prior to entering and leaving COVID-19 ICU.
Standards of Care and Pharmacy Considerations
The rapidly emerging evidence combined with an increase in demand of medication supplies required strategic planning to ensure safe and efficient care for patients. These plans included continuous updates to the electronic medical record system as guidelines and protocols were developed (eg, creation and implementation of an anticoagulation algorithm based on thrombotic risk)5. Drug shortages were another challenge faced during the pandemic, particularly medications required for critically ill patients6. Tactical utilization of analgesics, sedatives and neuromuscular blocking agents was crucial (eg, usage of remifentanil, hydromorphone and morphine were prioritized over the use of fentanyl when faced with fentanyl shortages).
The pharmacy department adapted rapidly to the ICUs expansion by changing workflows and increasing medication supply and delivery (eg, stocking of automated dispensing cabinets on the new units to mirror other ICUs, allocating the critical medications required for the neurocritical care to both COVID-19 and non-COVID ICUs).
Overall ICU Experience
Our hospital admitted a total of 730 COVID-19 patients during the surge period (April-June 2020), of which 270 required ICU admission. Of those 270 patients, 113 patients were admitted with symptoms related to severe acute respiratory illness in form of severe pneumonia or ARDS. Median SOFA score was 5, median SAPS II score was 31. Of the 113 patients, 77 patients (68%) required mechanical ventilation, 10 patients required VV ECMO support. Renal replacement therapy was required in 28 patients (25%). Overall mortality was 25% and mortality among patients requiring intubation and mechanical ventilation was 30%.
Stroke and COVID-19 Experience
Among all COVID-19 admissions to the hospital, acute cerebrovascular disease was seen in 5.2% of patients (3.2% ischemic, 2% hemorrhagic)7. In our series, patients with COVID-19 and ischemic stroke were significantly younger (58.74 vs 48.11 years), predominantly male (68.18% vs 94.74%), had lesser rate of cardiovascular risk factors and more severe clinical presentation (NIHSS 7.01 vs 17.05) compared to those ischemic stroke patients without COVID-19. There was also a remarkably high rate (75%) of large vessel occlusion (LVO) in COVID-19 patients with ischemic stroke, and 73% of these patients were below the age of 50 years8. LVOs were observed in multiple vessels (40%), uncommonly affected vessels, in atypical locations and had large thrombus burden. In these patients with LVO, ischemic stroke etiology remained undetermined in 46% of patients and functional outcome was poor. Similar to the reported data, the impact of COVID-19 was apparent in our stroke operational pathways with significant increase in time to initiate endovascular thrombectomy due to the institution of protected code stroke protocols.
Adapting to a crisis such as the COVID-19 pandemic whereby critical care services need to treat more patients with same staff and resources requires a multi-disciplinary, multi-faceted and interconnected approach to ensure the safety of the staff, optimizing resources utilization, continuous education and adaptive standards of care with constant communication.
- Huang, C., Wang, Y., Li, X., et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395(10223):497-506.
- World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard. World Health Organization.
- Moheet, A.M., Shapshak, A.H., Brissie, M.A., et al. Neurocritical Care Resource Utilization in Pandemics: A Statement by the Neurocritical Care Society. Neurocrit Care 2020;33(1):13-9.
- Alhazzani, W., Moller, M.H., Arabi, Y.M., et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med 2020;48(6):e440-e69.
- Atallah, B., Mallah, S.I.AlMahmeed, W. Anticoagulation in COVID-19. Eur Heart J Cardiovasc Pharmacother 2020;6(4):260-1.
- Atallah, B., Sadik, Z.G., Salem, N., et al. The impact of protocol-based high-intensity pharmacological thromboprophylaxis on thrombotic events in critically ill COVID-19 patients. Anaesthesia 2020.
- John, S., Hussain, S.I., Piechowski-Jozwiak, B., et al. Clinical characteristics and admission patterns of stroke patients during the COVID 19 pandemic: A single center retrospective, observational study from the Abu Dhabi, United Arab Emirates. Clin Neurol Neurosurg 2020;199:106227.
- John, S., Kesav, P., Mifsud, V.A., et al. Characteristics of Large-Vessel Occlusion Associated with COVID-19 and Ischemic Stroke. AJNR Am J Neuroradiol 2020.