How to set up an ICU

Over the last​  thirty years the number of hospital beds in England has dropped by more than half, to 141,000. This partly reflects a shift towards community care and operations that no longer need an overnight stay, but year after year the NHS endures a winter bed crisis. Last winter the average bed occupancy rate across all wards in England was 92 per cent and many individual trusts were running regularly at more than 95 per cent. This is despite the fact that hospitals are advised to have an occupancy rate below 85 per cent, to allow for fluctuations in the number of unwell people on any given day and for the time it takes to discharge patients (who usually have to wait for their paperwork or medication and to be picked up; once they’ve left, the next patient can’t move in until the space has been cleaned). Unlike the overall quantity of beds, the number of intensive care places hasn’t dropped over the years and currently stands at 4123 nationwide. (The ICU occupancy rate in January this year was 83 per cent across England but more than 85 per cent in London.) The UK, however, has fewer ICU beds than many other European countries. Germany has 29.2 ICU beds per hundred thousand people, whereas the UK has only 6.6 – the European average is 11.5. Both Italy and Spain have more than we do: 12.5 and 9.7 ICU beds per hundred thousand people respectively. Given that recent statistics suggest that up to 10 per cent of patients with Covid-19 require intensive care, and that a majority of people in the UK may ultimately be infected, there is an urgent need to create more ICU beds.

Hospital wards can be divided roughly into intensive care units, high dependency units and general wards. Intensive care is used for the most seriously ill, in particular those who need advanced support to breathe or those with two or more organ failures. Patients who need less significant respiratory support or help for only one organ system may be placed in a high dependency unit instead. An ICU is staffed by doctors who have trained in intensive care and anaesthetics as well as by specialised nurses. Each patient should have their own nurse.

It is unlikely that the UK will be able to build two brand new hospitals with functioning ICU beds in a fortnight, as China did, but the government has identified several venues that can act as Covid-19 emergency hospitals. These include the ExCel Centre in London (now up and running as NHS Nightingale) and other locations in Birmingham, Manchester and Glasgow. It is still unclear what level of care will be offered in these centres but, since we are told they will be equipped with oxygen and ventilators, they seem to be aiming to provide at least HDU-level care (you wouldn’t have patients who need ventilators on a general ward). In China, which is testing and containing confirmed cases far more thoroughly, entertainment venues have been adapted to isolate people with Covid-19 who have mild or no symptoms, in order to stop the rest of their household (or anyone else they come into contact with) becoming infected. They are not treating seriously ill patients in these spaces.

A large number of staff and a great deal of equipment will be needed to set up and run emergency hospitals with ICU or HDU capabilities. Personal Protective Equipment guidelines have changed constantly in recent weeks, making it confusing for staff. Anyone treating a patient suspected of having Covid-19 should at the very least be provided with a disposable surgical mask, gloves and a gown. When performing procedures like intubation which spray the virus into the air, staff need to wear a filtering mask (known as FFP3) and eye protection as well. The latest advice is that medical staff treating any patient in hospital should wear protective gear, but many hospitals are struggling to supply it – we are already having to reuse our goggles.

Tens of thousands of NHS staff have come out of retirement and others have been redeployed from areas where there is less urgent need (this includes staff who usually work in operating theatres, since most elective operations have been cancelled). Each day, as the situation grows worse, more doctors are told to move to critical care, even though many of us haven’t practised this sort of medicine since our initial training. Some London trusts have asked staff to work in the new Nightingale Hospital and have offered free hotel accommodation and taxi travel. The reduction in public transport has made it difficult for many doctors and nurses to get to work or made their commute far longer: in order to ease this burden, trusts have been making arrangements for free car parking and overnight accommodation if they can’t get home. Keeping staff numbers high enough is going to become more and more difficult. The NHS has been understaffed for many years and the problem is now compounded by the fact that up to 30 per cent of staff are self-isolating at any one time, sometimes simply because someone in their household is showing mild symptoms – a child who may just have a cold, for instance. Doctors who work in other hospital departments are terrified of inadvertently spreading the virus among patients of theirs who are already seriously ill. The introduction of mass testing should enable many to get back to work, but until then an unprecedented strain is being put on an overstretched workforce. Reliable antibody tests, over which there has been much excitement, are a long way off.

Most patients admitted to an ICU with Covid-19 will have respiratory failure caused by pneumonia and an acute immune response, sometimes in combination with heart failure or kidney failure. There is no treatment, only supportive measures. Intubation allows us to keep the airway open for a ventilator: a plastic endotracheal tube (ET tube) is inserted through the mouth or nose into the windpipe while the ventilator, which uses air or oxygen, pressurises the lungs to ensure that the narrow airways don’t collapse. Any new ICU bed will need not only these ventilators but oxygen and air plumbing too. At the end of March, the oxygen supply of a London hospital ran perilously low as a result of the dramatic increase in demand, putting at risk all patients reliant on oxygen, not only those with Covid-19. Patients with respiratory illnesses often need the secretions in their upper airways and mouth to be removed with suction, usually in conjunction with specialist physiotherapy. In intensive care units patients have continuous monitoring of their heart rate, blood pressure, oxygenation of the blood, breaths per minute, exhaled carbon dioxide levels and temperature. A machine displaying most of this information stands at the bedside, alongside numerous infusion pumps that provide medicine directly via an IV drip. You need a good electrical supply with lots of sockets for all this equipment; even the bed needs to be plugged in so you can nurse patients in different positions. Doctors in Italy have reported that patients with Covid-19 respond best when treated lying face down.

There are other logistics to consider. Secure and well-stocked drug rooms are required; a huge range of drugs is used in the most complex cases, including those critical to maintaining blood pressure, in addition to more common drugs such as antibiotics (for those with a bacterial infection on top of Covid-19), sedation, pain relief and fluids. The facility will also need to be able to run blood tests; most ICU patients require regular ‘blood gases’, which are run on a machine in the unit (rather than sent to the lab), giving results within minutes. Other blood tests will have to go to a lab and doctors will want results within an hour. There needs to be a portable X-ray machine to assess the lungs and check whether ET tubes and lines are in the correct position. And so radiographers have to be on hand to perform the X-rays, as well as porters to fetch and carry blood samples, and technicians to run the lab. It has to be possible to support any other organs that are failing; in the case of the heart this might mean medication such as inotropes (which increase the heart’s ability to contract) and if the kidneys are failing a dialysis machine. Providing all of this in an entertainment venue is a big ask.

The government and hospital trusts are looking at other ways to increase total bed numbers, and ICU beds in particular. Some private hospitals have agreed to provide services for NHS patients, which would be helpful for total bed numbers, but not for critical care: very few private hospitals have ICUs. Some ICU spaces might be created by repurposing empty beds in paediatric ICUs for adults, as children tend not to be severely affected by the virus. If HDU beds are upgraded to ICU beds, some of the general wards could in turn deliver HDU-level care. In a high dependency unit, patients are awake and breathe for themselves but their lungs can be supported through non-invasive ventilation (NIV). NIV is being used for Covid-19 patients across the world. Videos from Italian wards show patients looking like astronauts in their NIV helmets. The transparent plastic hood, which encompasses the whole head and is sealed at the neck, is recommended because there are concerns that using NIV with a simple face mask produces a spray of fine particles that float in the air, potentially infecting anyone in the vicinity, as opposed to droplets from a cough that quickly land on surfaces. Patients in HDU require close monitoring, including regular observations and blood tests; there should be one nurse for every two patients. It would make sense for patients needing even non-invasive ventilation to be based in existing hospitals and allow the new centres to replicate general wards, where a Covid-19 patient might be given oxygen via a mask or nasal prongs (this is not thought to spread viral droplets), as well as paracetamol and fluids. The latest figures for NHS Nightingale suggest that it will have a ratio of one nurse for every six patients.

If we are​  unable to provide the extra critical care beds we need, NHS staff could end up making some very difficult decisions. It may be that people who would normally be admitted to an ICU are rejected due to lack of space. In Italy the worst-hit hospitals have enforced a cut-off age of 65 for intensive care treatment. As younger people and those with fewer existing health issues are more likely to recover from Covid-19, they will be prioritised for beds. A study of patients in the UK already admitted to an ICU with the virus has shown that approximately 50 per cent of patients survive; the survival rate increases to 75 per cent for those under fifty but is only 26 per cent for those over seventy. More surprisingly there seems to be a gender imbalance too: 70 per cent of those admitted to an ICU with Covid-19 are male and your chance of dying is 53 per cent as opposed to only 37 per cent for women. We don’t yet know why. Other factors that make you less likely to survive an ICU admission are more predictable and include severe health issues, needing daily assistance and obesity.

Deciding who gets into an ICU is not the only difficult choice doctors will have to make. Hospitals are no longer allowing visitors on adult wards due to the risk of infection. Wards will soon be full of people who are dying on their own, whether from Covid-19 or other conditions, while family members wait at home for a phone call. Frail and already unwell people who aren’t candidates for ICU care will have to decide whether to be treated on a general ward, away from their family, or go home and isolate with them, possibly without the medical care they need. Palliative care teams will be in high demand in order to provide support for people at home with a dying relative. Those who are younger and healthier and make it into to an ICU may face competition for the highest level of care – extracorporeal membrane oxygenation (ECMO). Carried out by a machine which takes over the role of the lungs and heart when a patient’s organs are failing, despite support from ventilators and inotropes, ECMO is most often used for patients who have acute respiratory distress syndrome associated with a pneumonia, which is what manifests in patients with Covid-19 when they become severely unwell. There are only five hospitals in the UK that offer ECMO to adult patients (with around thirty machines between them) and patients already have to meet very strict criteria to be eligible. This is a scarce but lifesaving resource that will be in greater demand as the number of cases increase.

We don’t know what is about to happen. But we can be sure that the question will be asked whether, if we had done more to increase bed and staffing numbers (known to be dangerously low for many years), we would have been better equipped to fight the pandemic. An inquiry into the immediate response seems inevitable; it will have to address whether hospitals should have started preparing much earlier. Comparisons with other countries, particularly China, show how much more could have been done, and how much more quickly. We saw this coming. Only time will tell if our response was enough.

3 April