Preparing for COVID-19: early experience from an intensive care unit in Singapore

About a third of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) be-come critically ill and require intensive care unit (ICU) admission [1]. As the COVID-19 (coronavirus disease-19) outbreak spreads [2], ICUs outside of China need to prepare for a potential surge of critically ill patients and counter the high transmissibility of SARS-CoV-2 [3]. Liu et al. have described their important preparations [4], and we would like to expand on their good advice by sharing lessons learnt from our early experience. By 17 February Singapore the highest number of confirmed outside of mainland China several clusters of local All healthcare institutions adopted a common strategy of with isolation of all suspected or confirmed cases of COVID-19 in negative-pressure rooms. We were fortu-nate most ICU were single — this infra-structure was put in place following the outbreak of SARS in 2003.

Preparing for COVID-19: early experience from an intensive care unit in Singapore Mei Fong Liew 1,2* , Wen Ting Siow 1,2 , Graeme MacLaren 3 and Kay Choong See 1 Dear Editor, About a third of patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) become critically ill and require intensive care unit (ICU) admission [1]. As the COVID-19 (coronavirus disease-19) outbreak spreads [2], ICUs outside of China need to prepare for a potential surge of critically ill patients and counter the high transmissibility of SARS-CoV-2 [3]. Liu et al. have described their important preparations [4], and we would like to expand on their good advice by sharing lessons learnt from our early experience.
By 17 February 2020, Singapore recorded the highest number of confirmed cases outside of mainland China with several clusters of local transmission. All healthcare institutions adopted a common strategy of containment, with isolation of all suspected or confirmed cases of COVID-19 in negative-pressure rooms. We were fortunate that most ICU beds were single rooms-this infrastructure was put in place following the outbreak of SARS in 2003.
We realized preparing ICUs for patients with COVID-19 had numerous other requirements. First, infection control not only involved strict adherence to personal protective equipment for the individual, but also involved changes in group dynamics. We organized our ICU to mitigate the effects of any infected staff by avoiding poten-tial spread between teams (see Table 1). Related to infection control, the medical ICU was given the task to cohort suspect or confirmed cases, including with peri-and postpartum care of pregnant women. Second, evolving information necessitated rapid and regular communications with large, disparate groups of clinicians.
Third, we had to train non-ICU acute medical staff dealing with critically ill patients prior to ICU admission, especially for resuscitation. Fourth, we had to reexamine specific ICU services. Given that extracorporeal membrane oxygenation (ECMO) for severe viral pneumonia is well-established [5], we prepared to cohort all COVID-19 patients in the medical ICU and have a satellite team from the cardiothoracic ICU manage the ECMO circuit. Lastly, we realized staff morale took an early hit due to multiple factors, including increased workload due to implementation of strict infection control measures, uncertainty over the effectiveness of personal protective equipment, anxiety over the lethality of any infection, concern for the well-being of their family members and stigmatization by members of the public.
To address the various issues of infection control, information flow, resuscitation training, advanced ICU services and psychological well-being of staff, we formulated several principles and solutions, which we hope can help other ICUs prepare for COVID-19 (see Table 1). • A dedicated roster to segregate "clean" and isolation teams, and to provide for stand-bys • Provision of clean scrubs for HCW to change into before duty; showering facilities at the end of shift • Education and re-education on personal protective equipment and use of powered air-purifying respirators, especially for isolation teams • Allow isolation teams to have a 2-week off-duty observation period ("wash-out" period), after every period of ward cover if manpower allows • Simulation practice with personal protective equipment and use of powered air-purifying respirators will help identify gaps in the wards and prepare ISO teams for such scenarios • Simulation with limited team members per scenario, for example, 4 members per team, to allow acclimatization of HCW to perform resuscitation in smaller teams • Checklists for preparation of drugs and pre-prepared trolleys for equipment, for intubation, line setting and other procedures, to minimize staff movement and enhance efficiency • Creative ways to improve communications during resuscitation, such as utilization of a printed "Call Airway Team" card for difficult intubations, using a communication whiteboard in the patient room and using walkie-talkies to relay messages to staff outside the room for equipment and help