Experiences from the epicenter: an observational report on converting a post anesthesia care unit to a COVID-19 intensive care unit

The novel coronavirus emerged in Wuhan Provence, China in December 2019. Twenty-seven cases of pneumonia with unknown etiology were identified to be caused by a novel coronavirus (SARS-CoV-2) isolated from deep airway suctioning samples. Patients presented with similar symptoms including dry cough, fever, and dyspnea. Nearly all were noted to have bilateral lung infiltrates on imaging and in severe patients, common lab findings include elevated neutrophil count, D-dimer, BUN, and creatinine, and decreased lymphocyte count. Inflammatory markers have also been noted as increased. The disease caused by SARS-CoV-2 was named COVID-19 by the World Health Organization (WHO). On January 30, 2020 the WHO declared the COVID outbreak a Public Health Emergency of International Concern. COVID19 landed in New York City with its first confirmed case on March 1, 2020 and now is responsible for over 187,848 cases and 15,422 confirmed deaths as of May 14, 2020. As cases started to rise, people were encouraged to stay home and only leave for essential reasons, termed social distancing by public health officials. New York City closed nonessential businesses and schools mid-March in an attempt to limit viral transmission. Currently only essential personal are allowed to be working outside the home. St John’s Episcopal Hospital (SJEH) is a 257 bed urban community hospital in Queens that is home to 8 residency programs and a medical school clinical training program. SJEH was the first hospital in Queens to have a confirmed case of COVID-19. The patient was admitted onMarch 7, and up to 40 health care workers were quarantined for possible exposure from direct contact. The General Surgery residency was the first to modify scheduling, reducing housestaff to a skeleton crew to decrease exposure. On March 8, surgical residents transitioned to 12-hour shifts with reduced coverage. This eliminated 24-hour shifts, with the hope that residents would be better rested, maintain high efficiency, and decrease fatiguerelated errors in anticipation of a significant increase in patient volume. Simultaneously, elective surgeries were canceled due to limited coverage and to avoid possible exposure for noncritical patients. As the number of cases grew, New York State mandated that hospitals increase intensive care unit (ICU) bed capacity by 50%. The standard ICU capacity of SJEH is 16 beds. An ad-hoc ICU (termed the COVID-19 PACU ICU) was created in the post anesthesia care unit (PACU) to be staffed by surgical residents, 2 of whom were fellowship trained in critical care, and a boardcertified surgical critical care attending. A critical care medicine attending was also available for backup coverage. Resident schedule was divided between 3 teams (each subdivided into day and night teams): 2 for the COVID-19 PACU ICU and 1 general/ vascular surgery team working outside of the unit. This division allowed for adequate coverage of the COVID-19 PACU ICU, consults, and emergency surgeries. It also allowed for appropriate rest and a built-in redundancy to allow for coverage in the event of illness. As of May 14, 2020, Queens County had the highest number of confirmed cases in the United States at 57,865. Queens County also had the second-highest number of deaths at 4610 in the United States. Including the 9 ICU beds available in our COVID-19 PACU ICU, our hospital ICU capacity increased to 30 beds. The total number of beds available in Queens County was 146. Below is the prototype designed and implemented by the Department of Surgery to convert the PACU into the COVID-19 PACU ICU. The PACU is an open unit of 7monitored bays with 1 room capable of holding 2 additional patients for isolation. A PyxusMedStation, supply room, soiled utility room, andmultiple work stations are within the unit. The entire PACUwas converted to negative pressure. This study was registered with Research Registry under the UIN: researchregistry5627 and prepared in accordance to the STROCSS guidelines. Ethics committee approval was not necessary as no patient treatment protocols or interventions were being investigated. All treatment was within the current standard of care and the aim of the study is a retrospective observational discussion of the rapid setup of an adhoc ICU. St John’s Episcopal Hospital, Far Rockaway, NY