Structuring and restructuring COVID-19 Intensive Care Units: a systematic review

Estruturação e reestruturação das Unidades de Terapia Intensiva na COVID-19: revisão sistemática

Estructuración y reestructuración de las Unidades de Cuidados Intensivos en COVID-19: revisión sistemática

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

Infection with the SARS-CoV-2 virus represented a new context for healthcare. Faced with the expectation of increased demand for hospital care, health systems worldwide presented a worrying overload, directly impacting quality of care¹. Thus, interventions and restructuring of services were necessary, aiming for greater agility and effectiveness in serving the population and seeking to prevent the collapse of health systems in the face of the pandemic², mainly in the absence of effective vaccines and antivirals³.

As a result, Intensive Care Units (ICUs) had an exponential increase in hospitalizations, indicating urgency in decision-making by health managers. They are in the ICUs, where the necessary support for caring for critical patients is found. In the absence of this hospital sector, a significant risk can be presented to patients when there is a need for hospitalization, as occurred in the calamities faced during the COVID-19 pandemic⁴.

In the case of management in healthcare services, definitions were drawn up on the administration of these resources to assist in the process of coordinating the units, and these are differentiated into: human resources (HR), which concern the protection of the patient, the operator and the population, aspects of care; material resources (MR), which contrast physical-technical factors, quality improvement, equipment and accessories; organization/structure processes, which confront sectoral administrative bureaucratic actions⁵.

The definitions aligned by Coppola⁵ are based on benchmarking, a process of studying agreements and analyzing best management practices based on international laws and guidelines.

With this, an understanding of the ICU reorganization process emerged, focusing on Coppola’s⁵ definitions, which required the remediation of the emergency experienced by the world during the COVID-19 pandemic. It is worth highlighting that no previous studies bring together these elements of structuring and restructuring during the pandemic and that the reorganization of ICUs was a necessary action to achieve assistance.

Therefore, this study aimed to identify the elements related to structuring and restructuring ICU’s HR, MR, and organization/structurE processes during the COVID-19 pandemic.

During the first phase of study selection, 171 articles were found, with 30 articles duplicates were excluded, and 113 articles were analyzed by title and abstract, of which 110 were research related to pathologies/health situations that differ from ICU reorganization, and three were reports and were excluded from the study. Twenty-eight were selected for full reading; 11 did not answer the research question, i.e. did not contain elements of ICU restructuring; and 12 were letters to the editor, leaving five studies selected for qualitative analysis (Figure 1).

Figure 1
PRISMA flow diagram, which describes the process of searching, identifying, including and excluding articles

*Exclusion done by Rayyan revision manager.

Characteristics of eligible studies

Most of studies were published in 2021^12,4,13, mainly in Spain^13,14 and mostly indexed in Embase, in different journals. Regarding the identification of resources related to the reorganization of ICUs, the five studies showed significant responses within the definitions of resources described by Coppola⁵.

Table 2
Study characterization, Brazil, 2023

Table 3
Extraction of what refers to human resources, material resources and organization/structure processes, Brazil, 2023

Data analysis

Similarity analysis led to the composition of six core words, represented by the words COVID-19, patient, care, bed, ICU, and equipment. The branching among the six cores reveals how the terms are strongly interconnected and convey the notion of the aspects of resource management during the COVID-19 pandemic.

Figure 2
Similarity analysis tree among words from the text corpus, Brazil, 2023

The word COVID-19 presented as central, concerns the pandemic moment, strongly linked to the word patient. The word equipment covers two cores, with important terms in the restructuring process, linking the importance of protection and the use of PPE as well as intubation and the teamwork process in intensive care. Another analysis considered is the connection of the words bed, ICU and increase, which are aspects observed in all studies as the purpose of administration and increasing beds to meet the great demand of the pandemic. The branch to the nucleus encompassing the word care presents links that direct quality assistance and strengthen this action.

During the COVID-19 pandemic, HR in health systems were impacted. Studies report losses in the mental health of professionals working on the front line related to the high flow of work, exhausting routine, impaired sleep, stress in work settings, among other factors¹⁴. In the restructuring process, managers were concerned about developing actions that would minimize damage to professionals’ mental health, such as psychological care, hiring more professionals, overload control, and an air-conditioned environment ^4,11,14.

The correct use of PPE is an action to prevent the spread and contagion of the SARS-CoV-2 virus and should be encouraged throughout work settings, especially for professionals who work on the front line in ICUs¹⁵. The availability of this equipment must be carried out by hospital units as well as the implementation of protocols for its use^11,12.

Training professionals for ICU care was mentioned by Shaparin et al.¹² as a necessary activity, but the author makes it clear that there was no large-scale training, due to the high demand of patients in need of care, but to assist in this process, those who had expertise in critical care played a role of leadership in the units. This action is a strategy to avoid the occurrence of errors in practice or handling of some equipment, and consequently, provides patient safety¹³.

To meet hospitals’ demands and needs, prioritization scales were carried out, from the most severe to the least severe care^11,13. In the COVID-19 scenario, severity protocols helped in the flow of care, providing critical patients with the immediate intervention compared to those who were not so serious. This action also made it possible to reduce the burden on ICU professionals¹⁶.

For Do Prado et al.¹⁷, worker safety is considered part of patient safety, since adequate resources, prepared professionals, a favorable environment, and administrative protocols show improvement, both in the development of care and in patient health outcomes.

MR guarantee in ICUs enables the proper functioning and provision of quality service, since, to provide care to critically ill patients, there is a need for demand for adequate materials, ensuring the supply of all areas of restructuring, preventing the service suffers interruptions that are harmful to professionals and patients¹⁸. This resource is directly linked to the particularities of HR so that material, logistics, and supplies can be managed, and it is necessary to have good functioning to meet patients’ and professionals’ interests¹⁹.

Professional protection through the reduction of risk exposure in work settings is a guarantee of quality care²⁰. Therefore, when it comes to the availability of PPE, there are reported difficulties in ensuring the maintenance of this equipment, especially personal protective masks¹¹. After the guidance of the World Health Organization on the use of masks by the general population, to contain the infection by the virus that causes COVID-19²¹, there was a collapse in the distribution of these materials, causing an overload in the supplying companies and lack in hospitals. However, the guarantee of use by professionals was reported in most studies^11,12,14.

In ICU, oxygen therapy makes it possible to maintain the body’s metabolic balance, improve tissue and organ oxygenation, correct hypoxemia, and plays a fundamental role for patients with airway infections²². This resource proved to be of great value in ICUs²³. Some of those presented in this review developed the creation of their oxygen plants and ensured the supply of this resource throughout the pandemic^4,13. To supply oxygen, auxiliary materials are needed, such as multiparameter monitors, laryngoscope, laryngoscopy blades, intubation probe, cold light laryngoscope, blades nº 3 and 4, Guedel cannula, 20 ml syringe, clip, high flow, face masks and glasses⁴.

Electricity is a resource present in ICUs that cannot be scarce, since the operation of the entire care process requires electricity, as for the use of monitoring equipment, lung fans, defibrillators, lighting, and air conditioning of the environment was maintained through generators for ICU maintenance^12,13.

MR security in the restructuring process aims to optimize professional work, ensuring more accurate monitoring of patients and progress in clinical results. This process of maintaining materials must be assessed by managers to maintain the perpetuation of instruments with the profile of this care ward²².

This method revealed sectoral bureaucratic-administrative resources, which made up the process of structuring and restructuring the units. The main objective is to detail changes or the creation of new sectors resulting from the COVID-19 pandemic. The guarantee of adequate beds for the care of critically ill patients, either through the expansion of existing hospital units or the development of new emergency units.

Shaparin et al.¹² reported a 16-room sector shift from a surgical and anesthesiology wing to a 60-bed ICU COVID-19 unit in New York. The authors stated that the restructuring process was successful, and point to safety and commitment to well-being, preserving the quality of patient care. This process also made it possible to maximize professionals’ experience and effective communication. Even during the subsequent waves of COVID-19, the hospital maintained subspecialty availability for emergency procedures in operating rooms.

Similar aspects were observed in the study by Borel et al.⁴ However, the changes took place in a hospital restaurant for employees, which was transformed into a 43-bed wing for critical care of COVID-19 patients in Paris. For this, engineers and doctors guided the implementation of this reform, which took place in 15 days.

In mid-2020, shortly after the pandemic was declared, in New Delhi, construction began on a hospital center with a temporary ICU of 25,000 square meters, with 250 beds. Sing et al.¹³ stated that the unit had a high structural level. The ICU was integrated in an accessible way to other wards of the hospital, allowing access to the wards, which were occupied by patients who were discharged from the ICUs. The entire restructuring process took place in 15 days, similar in time to the project by Borel et al.⁴

Due to the reduction in the performance of elective surgeries in a tertiary hospital in Spain, its surgical wards were transformed into ICUs for patients with COVID-19. Vilallonga et al.¹³ reported the needs analysis process with the increased demand for critical care and the exhaustion of the 103 existing beds. The decrease in surgeries made it possible to create 120 new beds for high demand. The authors reported that this action avoided the increase in mortality rates, optimizing the surgical space as much as possible.

In this scenario, there was a great capacity for expansion in ICU beds in Spain. Nunez-Villaveiran et al.¹⁴ reported a 160% increase in beds in different hospital units resulting from COVID-19 infection. These actions are part of the human disaster prevention plan, as intensive care resources have been increased to accommodate large numbers of critically ill patients.

The limitation of this review is identified by the specificity of the subject and consequent reduced production on the topic. Moreover, we limited the language of the studies and only included studies available online. However, an exhaustive analysis of the elements identified was carried out, which improved the results.

The study could serve as a guide for managers and healthcare professionals to understand the process of reorganizing ICUs, aimed at caring for patients with COVID-19.

The main elements necessary for structuring and restructuring ICU to meet the pandemic scenario demands are HR: professional training to care for patients with COVID-19 and correct use of PPE, an increase in the number of healthcare professionals, an increase in strategies for team and patient well-being, relocation of professionals among care sectors, presence of psychologists in services to assist professionals and greater adherence to the use of PPE; MR: increased supply of adequate PPE, increased supply of oxygen, increased supply of medications and increased need for equipment such as anesthesia circuit filters, mechanical ventilators, intubation boxes and other equipment for airway management; and organization/structure processes: increased demand for hospitalization beds, including ICU, and adaptation of facilities for COVID-19 hospitalization sectors.