Description of an Integrated and Dynamic System to Efficiently Deal With a Raging COVID-19 Pandemic Peak

Background This study aimed to describe an innovative and functional method to deal with the increased COVID-19 pandemic-related intensive care unit bed requirements. Methods We described the emergency creation of an integrated system of internistic ward, step-down unit, and intensive care unit, physically located in reciprocal vicinity on the same floor. The run was carried out under the control of single intensive care staff, through sharing clinical protocols and informatics systems, and following single director supervision. The intention was to create a dynamic and flexible system, allowing for rapid and fluid patient admission/discharge, depending on the requirements due to the third Italian peak of the COVID-19 pandemic in March 2021. Results This study involved 142 COVID-19 patients and 66 non-COVID-19 patients who were admitted; no critical patient was left unadmitted and no COVID-19 severe patients referring to our center had to be redirected to other hospitals due to bed saturation. This system allowed shorter hospital length-of-stay in general wards (5.9 ± 4 days) than in other internistic COVID-19 wards and overall mortality in line with those reported in literature despite the peak raging. Conclusion This case report showed the feasibility and the efficiency of this dynamic model of hospital rearrangement to deal with COVID-19 pandemic peaks.


INTRODUCTION
Since its onset, the COVID-19 pandemic has pressured healthcare systems worldwide. We previously described a functional and dynamic strategy that allowed our intensive care unit (ICU) to deal with the first two peaks of the pandemic, in March and October 2020, that in our community reached 8.2 cases per 1,000 inhabitants (1). The setting is a public hospital of 450 beds, which is a reference point for a population of about 210,000 people. Before COVID-19, the ICU consisted of 18 beds, whereas during the pandemic, 6 non-COVID ICU beds and 9 step-down unit (SDU) beds were opened.
This case study aimed to show how this dynamic system has been furtherly implemented to deal with the third and strongest pandemic peak, in March 2021, reaching a local incidence of 13.3 positive cases per 1,000 inhabitants (62% increase).

METHODS
As the third peak was arising, all the hospital non-COVID wards were promptly resized and relocated. Strategically, the first units left empty were those close to the ICU-SDU (4 th floor) and to the COVID-internal medicine (6 th floor). With respect to the previous strategy, a further internistic COVID unit, General Internal Medicine Ward COVID-19 (GW C19 ), of 16 beds was carved out on the 4 th floor, next to the SDU (Figure 1). It was staffed by an intensivist physician, with an 8:1 patient-per-nurse ratio (PPNR), wherein nurses were not ICU-trained. Two monitored beds (oxygen saturation, non-invasive or invasive blood pressure, and ECG) for patients needing high flow nasal cannulae (HFNC) were available. Admission criteria to this general ward were the following: patients positive to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with radiologic evidence of pulmonary interstitiopathy, dyspnea, oxygen saturation (SpO 2 ) ≥ 92% on room air, and low oxygen supplementation (less 10 L/min). Clinical factors, such as fever, hypertension, and diabetes mellitus, were considered risk factors for possibly severe evolution (2).
The 4th floor, under the control of the intensive care department, thus counted on the following: 16 GW C19 beds, 1 intensivist, 8:1 PPNR; 9 beds SDU, 1 intensivist, and 3:1 PPNR (at least 1 ICU-trained nurse); 11 ICU1 beds, 2 intensivists (1 during the night shift), and 2:1 PPNR; 7 ICU2 beds, 2 intensivists (1 during the night shift), and 2:1 PPNR; 6 ICU3 beds, 1 intensivist, and 2:1 PPNR (Figure 1). Admission criteria to SDU were previously described (1). This was made possible by a drastic 50% reduction of the planned operating room activity, actuated for safety reasons, that allowed to recover a sufficient number of anesthetists to be employed at the 4 th floor. In Italy, anesthesia and intensive care still constitute a single residency program, thus specialists are certified and trained to manage complex patients with one or more ongoing organ failure.
In March 2021, the Italian Ministry of Health published new guidelines on the management of isolation of severe COVID-19 patients: (3) 21 days after the first SARS-CoV-2 positivity, if asymptomatic or with a negative molecular test, they were considerable non-infective and transferable to non-COVID units. This increased the fluidity in the management of bed occupancy. oICU C19 refer to nearby hospital ICUs collapsed during the pandemic peak, which referred 5 of their supernumerary patients to our ICU C19 . Other patients were carried from the ambulances directly from nearby provinces to our emergency department. As soon as they were stabilized and a bed was available in their local ICU or hospital, they were discharged outside our hospital. A geriatric ward (GeW C19 ) was also available for elderly patients in our hospital, although not described in the paper. When a patient fulfilled the admission criteria, he was admitted to the GW C19

RESULTS
In March 2021 (31 days), a total of 142 COVID-19 patients and 66 non-COVID-19 patients were admitted to the 4 th floor. Table 1 describes the characteristics of these patients. The 4th-floor setting allowed to admit every patient to a level of intensiveness appropriate for their clinical status.
Mean (± SD) LOS in GW C19 was shorter than in other internistic COVID-19 wards: 5.9 (4) days vs. 11.8 (5) days (p < 0.0001; unpaired t-test). This is probably due to the higher rapidity by which patients were transferred to a higher level of care through early detection of clinical deterioration and simple transfer systems or to the mindset of intensivists used to working with short timescales. All patients with severe COVID-19 who were referred to our hospital have been hospitalized, none needed to be referred to other hospitals, thanks to a system that avoided hospital bed saturation.

DISCUSSION
The decision to staff the GW C19 with anesthesiologists/intensivists was proposed by the hospital direction due to staff contingency. The director of anesthesia and ICU and the collaborators agreed with this setting, to ease and improve the management of patient discharge from ICU and SDU, trying to avoid bed saturation. Being part of the same team, sharing the same protocols, informatics system (Margherita 3), and coordinators allowed considerable time-saving. This was an efficient solution to maintain a safe and balanced hospital environment.
Differently from the previous report from March and April 2020, SDU worked more as a high dependency unit (HDU), at a semi-intensive care level, more complex than a common step-down unit (6). Furthermore, 8 patients were transferred from ICU C19 to SDU without requiring invasive ventilation; of the 41 patients admitted in SDU, only 11 needed escalation to ICU C19 for higher monitoring or orotracheal intubation; 34 patients were admitted directly from the emergency department (ED) to SDU. These data seem to testify to the high intensity of care reached in SDU at this third wave.
A limitation of this report is that, by its nature of case study, it is not matched with a comparative system. Moreover, at first superficial sight, the employment of intensivists in GW C19 and SDU might seem a waste of resources. In our experience, this has allowed many physicians to cyclically work at a lower intensity, periodically decompressing from the stress and pressure of a year in an ICU C19 , interacting with conscious patients experiencing better outcomes, thus reducing burnout problems (7).
A further limitation of this system is that it worked in our specific context, whereas, it might not be applicable for hospitals acting as referral centers for a much wider general population and it might also not be applicable to regions where the incidence rate is much higher, determining a dramatic pandemic wave.
The model of differential intensity for hospital care management (high-intensity for ICU, medium-intensity for SDU, and low-intensity for GW), handled by a single intensive care unit, determined a sort of independence of the 4 th floor from the hospital. The 4 th floor was able to admit COVID-19 patients from other units/floors as needed from their clinical status evaluated by a consultant, but internally there was no need for hospital bed-manager coordination, counseling requests, bureaucracy, and time-wasting procedures.

CONCLUSION
The use of a COVID-19 "critical floor" from the general ward to ICU is an example of system adaptability. The effort made by intensivists was useful for patients in terms of quality of care and doctors in terms of occupational stress and mental health.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

AUTHOR CONTRIBUTIONS
VA conceived the study and wrote the article. EG, AC, CM, DS, and GBo worked in COVID-19 ICU and wards and helped to write the article. GBa, MS, and PC coordinated the nursing staff in the management of the ward. LM, FC, CLu, MA, CLa, and VP collaborated to review the manuscript. ER helped to write the manuscript and provided supervision. All authors contributed to the article and approved the submitted version.