Contingency plan for the intensive care services for the COVID-19 pandemic



# Introduction
On 7 January 2020, the Chinese authorities identified a new virus belonging to the family Coronaviridae as the cause of an outbreak of pneumonia cases in the city of Wuhan, in the province of Hubei. The virus was subsequently referred to as SARS-CoV-2, and the disease it causes became known as COVID-19. [bib_ref] Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in..., Wang [/bib_ref] According to data from the European Center for Disease Prevention and Control (ECDC), between 31 December 2019 and 16 March 2020, the disease had spread to 139 countries, with the declaration of 16,741 cases, including 6507 deaths.In Spain, information from the Ministry of Health indicated that at 13:00 h on [bib_ref] Critical care management of adults with community-acquired severe respiratory viral infection, Arabi [/bib_ref] March there were 9191 positive cases in the country, of which 432 corresponded to patients admitted to Intensive Care Unit (ICUs).In this scenario, the scientific societies SEMICYUC, representing specialists in Intensive Care Medicine, and the SEEIUC, representing nursing professionals dedicated to critical patient care, contemplated the need to develop a contingency plan to address the demands associated with this new disease, with the following objectives in mind:
1 To provide the health authorities and managing bodies and clinicians with a technical document addressing all aspects related to identification of the healthcare needs of seriously ill patients in the face of the pandemic caused by the new SARS-CoV-2 virus, with a view to allowing integral and realistic planning of the Departments of Intensive Care Medicine at national and regional level, and in each hospital.

## Previsions for the covid-19 pandemic
The planning of possible scenarios is based on the use of FluSurge 2.0. This software was developed by the Centers for Disease Control and Prevention (CDC), and offers a free access spreadsheet to perform approximate calculations of the service demands in situations of a moderate to severe pandemic.The tool allows us to modify the population at risk, the available hospital resources and the assumptions referred to the epidemiologic course of the pandemic----yielding an approximate estimate of the needs in that context. Accordingly, the programme estimates the number of hospital admissions and deaths, the number of hospitalized persons, the number of patients requiring admission to the ICU, the number of these individuals who require mechanical ventilation, and the degree of saturation of the available services for dealing with these patients. It is important to mention that FluSurge 2.0 was specifically designed to consider the possible effect of an influenza virus pandemic, and has only been validated in that context. Its application to the COVID-19 pandemic must be assessed with caution.
The calculation of the possible scenarios requires a series of initial assumptions regarding the characteristics of the pandemic. The estimates used are based on the published series corresponding to the Chinese outbreak, 5,6 the Italian experience with the disease, 7 and the experience gained from influenza virus H1N1. [bib_ref] Patients with influenza A (H1N1)pdm09 admitted to the ICU. Impact of the..., Marin-Corral [/bib_ref] The assumptions were a mean hospital stay of 11 days, a mean ICU stay of 14 days, 11% of hospitalized patients requiring admission to the ICU, and 6.5% requiring mechanical ventilation.
Considering an attack rate (proportion of people within a population who suffer contagion by a given disease) of 35% and a duration of the pandemic of 12 weeks (data which are adjusted to the evolution of the most severely affected Spanish Autonomous Communities), the following is contem- o Need for over 5000 respirators in the weeks of greatest demand.
The contemplated scenario is conceived to plan the needs in the event the containment measures are insufficient. The following is recommended:
o Planning according to the actual situation in each moment. o Reassessment of the evolution in response to the containment measures.

## Pandemic response phases
It is advisable to adjust the response according to the evolution of the pandemic. [bib_ref] Critical care crisis and some recommendations during the COVID-19 epidemic in China, Xie [/bib_ref] 

## Human and technical resource requirements coronavirus committees
Coronavirus committees are working groups at national, regional and local level (pertaining to the hospital) that prepare the necessary resources and action plans in the face of all the possible scenarios.

## Technical resources
The following recommendations are made:

## Human resources
Each center requires a care modification plan contemplating the distribution of workloads, care responsibilities and working hours or shifts.
The following is recommended in reference to intensivists o Normal work shift:
-An intensivist for every three patients.
-In the event of saturation, other non-intensivist physicians (including residents in training) may be incorporated, coordinated by an intensivist. o Duty shift:
-Two intensivists or an intensivist plus a fourth-or fifthyear resident for every 12 beds. -In the event of saturation, other non-intensivist physicians (including residents in training) may be incorporated, coordinated by an intensivist.
The following is recommended in reference to nursing staff [bib_ref] Nursing activities score, Miranda [/bib_ref] o Reinforcement per shift for every 8---12 beds for organization and cleaning of material, support and replacement.

## Staff training 9
o The SEMICYUC will generate training material: charts, diagrams, posters, etc. o Each hospital should organize training sessions with at least the following contents: -Epidemiology of COVID-19.
-Impact upon activity.
-Transmission.
-Diagnosis of COVID-19.
-Personal protection measures: personal protective equipment (PPE), procedures and isolation.

## Internal communication. transmission of information
We recommend the following [bib_ref] Handover in intensive care, Sirgo Rodriguez [/bib_ref] :
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## Communication with and information for patients and relatives
o In those ICUs with cases of COVID-19, it is advisable for the families of all the admitted patients to be informed of the fact on a daily basis, as well as of the moment in which there no longer are any such cases----without providing any other type of information that may affect the intimacy of such patients and their families. o In those ICUs with cases of COVID-19, it is advisable for the families of the admitted patients to receive the usual daily information from the team outside the Unit. o The patients with COVID-19 are to be isolated, with absolute restriction of accompaniment/visits. Only in situations analyzed on an individualized basis by the medical team, due to strict necessity (e.g., in imminent death situations) or based on other clinical, ethical and/or humane considerations, will limited, controlled, brief and supervised visits be allowed, after instructing the relatives on how to wear and remove the PPE, with due help and supervision. o The families are to be advised to minimize patient accompaniment as far as possible, regardless of whether the patient has COVID-19 or not. o Visits to patients without COVID-19 in Units where COVID-19 cases are present are to be adapted to the architectural characteristics of the Unit.

## Optimized use of resources
Coronavirus is mainly transmitted by respiratory droplets measuring over 5 m in size and through direct contact with the secretions of infected individuals. It may also be transmitted by the aerosols produced during therapeutic procedures. We therefore recommend the following

## Personal protective equipment
Such equipment must include-Prepare the sample for transport in the box.
-Clean the outer part of the tube with surface disinfectant or a small towel impregnated with disinfectant. -Sample transport is to be done personally, avoiding transport systems such as pneumatic tubes. o The professionals in charge of the patient must supervise any intervention upon the patient by staff not belonging to the Unit.

## Indications of admission to the icu in patients with sars-cov-2 pneumonia
General criteria for admission to the ICU We recommend the use of objective ICU admission criteria based on the recommendations of the American Thoracic Society (ATS), the Infectious Diseases Society of America (IDSA) 20 and the recent evidence of the analysis of the SARS-CoV-2 (COVID-19) epidemic in China 21 [fig_ref] Table 1: The following are exclusion criteria for admission [/fig_ref]. Admission to the ICU is to be considered in the presence of one major criterion or three or more minor criteria.

## Optimization in case of saturation
o In cases of saturation or overwhelming workload, priority must center on those patients most likely to recover. o The ICU triage or screening protocols referred to pandemics should only be activated if the ICU resources in a large geographic area have become or are going to become overwhelmed despite all reasonable efforts to expand resources or obtain additional resources. o It is essential to have guidelines on the adequacy of therapeutic effort.

## Inclusion/exclusion criteria 22---25
o A screening instrument capable of objectively classifying the patients is advised.

## Expansion plan
The expansion plan includes the transformation and preparation of additional spaces for the care of critical patients in situations of ICU bed collapse, as well as an increase in the number of staff members with expertise in the care of critical patients.

## Expansion of the departments of intensive care medicine
The possible locations for the stay of critical patients must be equipped with [bib_ref] Recommendations for intensive care unit and hospital preparations for an influenza epidemic..., Sprung [/bib_ref] 

## Conflicts of interest
None.
[table] o: Protective clothing and gloves. o Respiratory protection. o Protection of the eyes and face. The following recommendations are made with regard to respiratory protection 14,16 Patients with confirmed infection and cases under investigation should wear surgical masks, if possible. o Use two high efficacy antimicrobial filters (inspiratory and expiratory arms) in the case of invasive mechanical ventilation. 18 o Use closed aspiration systems. o In the case of noninvasive ventilation, it is advisable to use antiviral filters and preferably double tubing equipment. o Avoid manual ventilation with bag mask. If done, use a [/table]
[table] Table 1: The following are exclusion criteria for admission: -Poor prognosis despite admission to the ICU.-Need for resources that cannot be provided.-Failure to meet severity criteria. o Application can be made of the specific recommendations on admission exclusion referred to mass casualty events.25 [/table]