ICU Lessons on COVID-19 From Italian Front Line: Be Flexible

Liam Davenport

March 24, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

The rate of increase in intensive care unit (ICU) admissions in regions gripped by the COVID-19 epidemic may take more than 4 weeks to peak, and even then only begins to slow down after another 4 days, warns an Italian academic, who is calling on countries not yet overwhelmed to prepare now as best they can.

Davide Manca, PhD, professor of process systems engineering at the Polytechnic University of Milan, Italy, predicts that, based on the above numbers and people continuing to respect the quarantine there, it could be that the rate of increase in patients needing ICU beds might start to fall by early April.

Using official Italian data in his short report, published online March 19 by the European Society of Anaesthesiology, he shows that the average time spent in the ICU in Italy by a patient with COVID-19 is 15 days, with a minimum of 10 days.

This is crucial to know for the planning of healthcare services and ICU provision elsewhere, he emphasized.

And he stressed that people facing this pandemic have to adopt a wartime mentality. Although the provision of ICU beds can be quickly ramped up, the quality of newer beds may not be optimal, for example, he explained.

"This means that best practices and standard assumptions...must be relaxed, or changed, or wisely adapted. Everything must be done quicker to find solutions."

This includes use of technologies such as continuous positive airway pressure (CPAP), which can be used to help reduce the number of patients who need ventilation in intensive care.

The number of confirmed cases in Italy today stands at more than 63,000. Many of these patients have severe symptoms, with signs of respiratory failure, and end up in ICU requiring intubation and ventilation.

Deaths have exceeded 6000 in the country, overtaking China.

Number of Patients With COVID-19 in ICU Doubles Every 2 to 3 Days

Manca has calculated from the Italian data that the number of patients in intensive care with COVID-19 initially doubles every 2 to 3 days.

This rate slows fractionally every day until, after 3 to 4 weeks, the doubling time is around 4 to 5 days. Around day 18, the rate of increase is maintained for 3 to 4 days without increasing further, known as the "inflection point", after which the rate of increase in ICU cases begins to drop.

He found that the inflection point was reached in Lombardy 19 days after the outbreak started in the region.

For the rest of Italy, that point will not be reached until the start of next month, he therefore predicts. The consequence is that "every day counts," he stressed.

"After the inflection point, the rate of increase slows down progressively — although overall numbers still increase steadily — until it flattens, with no further increase in the rate of people entering intensive care."

"The best estimate of when this will occur in Italy [based] on these data is between days 38 and 40 [after the first patient entered ICU], which is to say in the first few days of April."

Reducing the Peak of the Tsunami: Adopt a Wartime Mentality

Manca emphasized his research should nevertheless be interpreted with a modicum of caution.

"This prediction is an extrapolation of the data...and will depend on how effective Italy's quarantine measures are in these next 2 weeks," he said.

On this issue, he noted, "Various reports are showing many people in Italy are not respecting the quarantine and social distancing rules."

"If other countries want to have enough ICU beds to treat all the COVID-19 patients that are going to be arriving at their hospitals, they have to decrease the peak of the tsunami of cases," he added.

Speaking to Medscape Medical News, he said countries such as the United States and UK — the latter is believed to be just 12 to 15 days behind Italy in terms of the rise in cases — should take heed of the Italian experience and "prepare."

Stressing that he hopes the number of cases will be lower in the UK, it nevertheless means "you have 10, 12, 15 days to take action" there.

Manca said he spoke to the head of Lodi Hospital in Lombardy after he had addressed almost 1000 anesthesiologists and resuscitation physicians in the UK via webinar, and was told UK clinicians have "very strict, very well-defined practices, and this is a very good point in peacetime but it might become a very critical point in wartime, and this is wartime."

He cautioned that UK clinicians may therefore not be sufficiently adaptable in their approach.

In the presence of the COVID-19 pandemic, "you cannot apply the good practices you use, for instance, in terms of intubation, because intubation must happen much faster."

"It will not be optimal, it will not be the best intubation, but if you apply the standard approach...people die."

It's Not Over When the Patient Leaves the ICU

The period covered by Manca's report starts on day 1, February 22, the first day a patient infected with COVID-19 was admitted to ICU in Italy, and runs to day 26, which was on March 18.

This first patient in the ICU — who is still alive — was 38 years of age when he was admitted. He had no comorbidities and was physically fit, playing football regularly.

He has now been discharged from the ICU, but the pressure on the healthcare system does not end there as he is now in a sub-ICU ward.

"He could start speaking a few days ago," Manca said, and he was able to see his wife, who is expecting a baby, for the first time since he was admitted, albeit through glass, as he is still positive for the virus.

"When they go out of ICU it means that they are no longer intubated, and they start breathing, however, with oxygen or enriched air, as they are not capable of breathing alone like normal people."

"It's not that they can go out and can start living again. It is [still] very tough," he explained.

Worse Than a Field Hospital

In response to the crisis, there has been a huge increase in the ICU bed capacity of hospitals in Italy.

Lombardy, which is at the epicenter of the disease, previously had 500 public ICU beds and 140 in private hospitals, a figure that has rocketed to more than 900 since the epidemic struck.

Other regions in Italy, estimated to be 10 to 12 days behind in terms of the impact of coronavirus, are following suit, rushing to increase their ICU capacity by converting standard wards into intensive care facilities, for example.

Although the conversion of wards into ICUs can be completed in days, or in some cases hours, Manca found a major problem has been the appropriate allocation of human resources and skillsets to be able to manage critically ill patients and the equipment.

It is also "very important" to realize that, as a consequence of these rapid changes, "the quality of ICU beds is decreasing day after day," he said, adding that, typically, "when you create a new [ICU] bed, it is not a very good one."

"The quality is not the same as in...a dedicated ward for ICU patients," and can be "worse than in a field hospital."

Regardless of the quality of new beds being created, the region of Lombardy has been at "saturation point" for a number of days.

Although the latest numbers suggest the situation has stabilized, this is partly because ICU patients are being moved out of the region, he observed.

CPAP Could Help Avoid ICU Admission

One important observation that has arisen from the analysis is that CPAP devices may help delay respiratory failure, thus helping medical staff to avoid ICU admission of patients when intubation is not feasible or available.

CPAP devices, used to treat conditions such as obstructive sleep apnea, are not usually employed in the ICU setting because "you would [preferentially] go for intubation," Manca said.

But intubation "is very hard" and, "if you have to intubate these people for a long time, you are increasing their risk for bacterial infection," he explained.

Moreover, "not all medical doctors and surgeons are capable" of performing intubation, "and so they are only using [it] as a last resort."

CPAP, which can be performed by nurses, can help reduce the number of patients requiring intubation and so save ICU beds for those who really need them.

A limiting factor, however, in using CPAP may become the oxygen pressure in distribution lines.

Rationing ICU Beds: "Now They Have to Choose"

These latest Italian data also indicate that ICU beds are being rationed, with patient age a commonly used criterion for selecting patients, Manca explained.

"Medical doctors swear to treat everybody independent of their age, sex, gender, religion, and so on," he added, "but now they have to choose."

The UK National Institute for Health and Care Excellence (NICE) published a COVID-19 rapid guideline on critical care on March 21, which emphasizes all patients be assessed using a recognized frailty score before being directed to intensive care.

Manca agreed with this approach, saying the crisis has meant each hospital in Italy is having to create its own rules for ICU admission, with the selection based on physical status now a commonly employed criterion.

The Illusion of Steady-State Admissions

Finally, Manca warned that in regions of Italy where the numbers for ICU admissions are currently low, it can appear as if the number of patients is not increasing.

But this may hide the reality of the situation.

"This is, on the one hand, very good, but it may mean that, for instance, two people died and two people came in. The number of ICU patients is the same," he said.

"But it's not the same because the pandemic has slowed," but rather because "there is a steady-state condition" between the number of people admitted to ICU and those who die, with always the potential for these numbers to rapidly increase.

The data for Manca's report were obtained from those made available by the Italian Health Ministry every evening, and his conclusions are based on numerous interviews with heads of ICUs and resuscitation units in Italy.

The report itself was reviewed by the heads of anesthesiology and resuscitation at the Carlo Besta Neurological Institute in Milan and Lodi Hospital, Lombardy, and analyzed by an intensive care clinician at San Paolo Hospital in Milan.

Manca's lab has received European and national research grants. He has reported no relevant financial relationships.

European Society of Anaesthesiology. Published online March 19, 2020. Report

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