Figure 1
Houston Methodist intensive care unit (ICU) COVID-19 census, bed capacity, and bed types. (A) The peak ICU COVID-19 census was 184. (B) ICU bed capacity jumped from 309 beds before COVID-19 to 352 during infection surges. (C) Bed types included COVID-19–positive patients, COVID-19–negative patients, and hybrid beds. During the first surge, Houston Methodist suspended all elective, nonurgent surgeries in an effort to reduce demand for critical care beds. In May 2020, all surgeries and procedures resumed. The peaks that followed required increasing ICU bed capacity to accommodate COVID-19–positive patients as well as postoperative patients.
Figure 2
Houston Methodist COVID-19 outcomes. ICU: intensive care unit; LOS: length of stay.
Figure 3
Key forces changing the face of the intensive care unit (ICU). ECMO: extracorporeal membrane oxygenation; IMU: intermediate care unit; PPE: personal protective equipment; AI: artificial intelligence.
Table 1
Summary of the initiatives introduced at Houston Methodist to improve staff resilience and decrease burnout. ICU: intensive care unit; PPE: personal protective equipment.
| STAFF SAFETY INITIATIVES | DESCRIPTION |
|---|---|
| Communication | • Town hall meetings were held to address concerns of the healthcare workers. |
| Music therapy | • Music therapy was used to calm staff anxiety stemming from the pandemic. |
| Adopt-a-unit | • COVID ICU was adopted by a non-COVID unit for 6 weeks, with staff in the COVID units receiving miscellaneous gifts and notes of affirmation and gratitude. |
| Mindfulness training | • Guided meditation was offered through a virtual platform, creating a systemwide mindfulness pause. |
| Safe rooms | • Family rooms in the ICUs were converted into “safe” rooms where the staff could unwind and relax during their ICU shifts. |
| Peer support | • Behavioral experts were available for anyone who needed a mental health consultation. • A dedicated chaplain was available to educate physicians and staff on stress management skills and adaptive/maladaptive coping skills. |
| Protecting staff | • Adequate PPE and powered air purifying respirators (PAPRs) were available to all healthcare workers. • Virtual rounding was done through tele-ICU–enabled laptops outside patient rooms to mitigate the risk of transmission. • Staff underwent frequent testing for COVID-19 and had prioritized access to the COVID-19 vaccine. |
Figure 4
Intensive care unit (ICU) innovations generated by COVID-19. IV: intravenous; DIY: do it yourself.
Video 1
Overview of Houston Methodist intensive care unit response to the COVID-19 pandemic. https://youtu.be/u1XAko0Ra9I
Figure 5
Triage algorithm for extracorporeal membrane oxygenation (ECMO) utilization in COVID-19 patients with acute respiratory distress syndrome (ARDS). (1) COVID-19 patients with ARDS are placed on mechanical ventilation adhering to institutional guidelines for ARDS management. (2) Prone therapy is strongly recommended in all patients with moderate to severe ARDS and should be performed if the patient’s PaO2/FiO2 (P/F) ratio is < 150. These patients should also be considered for pulmonary vasodilator therapy, especially if proning is contraindicated or the patient’s oxygenation does not improve or worsens with prone therapy. (3) Despite these interventions, if the patients’ P/F ratio is still < 150, these patients should be placed on ECMO watch. (4) The ECMO team consisting of cardiovascular (CV) intensivists, CV surgeon, and ECMO specialist uses a multidisciplinary approach based on current guidelines to determine whether a patient should be placed on ECMO. If so, perfusionist and ECMO specialists prepare supplies and medications for cannulation. The patient is then cannulated by a CV surgeon. Institutional guidelines are followed for the appropriate donning of PPE prior to insertion of ECMO. (5) ECMO is managed by the CV intensivist. An ECMO specialist is stationed in the ICU for close patient monitoring. All issues are directed to the CV intensivist, who can monitor ECMO patients via the virtual ICU cameras. Automatic ethics and palliative care consults are generated for every ECMO patient. The ECMO team continues to assess the benefits of ECMO on a regular basis and holds family meetings regularly. (6) The critical care intensivist continues to manage all other critical care aspects of the patient and work closely with the ECMO team. ARDS: acute respiratory distress syndrome; PPE: personalized protective equipment; CV: cardiovascular; ICU: intensive care unit.
Table 2
Virtual intensive care unit (vICU) contributions to a changing ICU during COVID. PPE: personal protective equipment; CV: cardiovascular; ECMO: extracorporeal membrane oxygenation.
| CHALLENGE | CONTRIBUTION |
|---|---|
| Shortage of PPE | • Enabled contact-free consults where specialists use vICU cameras to assess ICU patients • Positioned local vICU-enabled laptops outside patient rooms in the COVID-19 ICUs to eliminate the need for donning and doffing of PPE |
| Restricted family visitation | • Used vICU infrastructure to implement remote family visitation program |
| Shortage of staff and ICU beds | • Increased staffing and bed capacity by deploying virtual critical care physicians and nurses to augment bedside ICU clinicians • Provided oversight of non–critical-care providers during peak of pandemic when critical care specialists were assigned to manage COVID-19 patients |
| ECMO support | • Used vICU-enabled laptops to allow communication between CV intensivists outside the ICU and CV surgeon/ECMO team operating inside to limit essential personnel |