1/ Thankful for all the thoughtfulness of @UMichMedicine leadership preparing for & managing #COVID19. This past week I got to help launch a “Pop-Up ICU” to expand our ICU capacity, led by @DrHasanAlam & Dr. Pauline Park.

Learned a ton from the frontline...

2/ First, some context. In the wake of H1N1 & 9/11, our recently built @MottChildren (2011) included a dedicated floor with isolation hallways & negative pressure rooms that could readily flex into a pandemic Regional Infectious Containment Unit (“RICU”)

https://www.uofmhealth.org/news/archive/202003/michigan-medicine-announces-covid-19-unit-new-paid-sick-time

3/ The 32-bed RICU served as the primary triage point for COVID patients, but more capacity was needed. Multiple areas of the hospital – stepdown units, PACUs, etc – were identified as potential ICUs. The rest of this thread relates to creating one “Pop-Up COVID ICU."

4/ Timing. We started well before we thought we needed it. This allowed for some structural changes, like converting regular rooms into negative pressure isolation rooms. Doing so required the room be vacant 24 hours for facilities to make changes and for engineers to test them.

5/ Repurposing Existing Space. In line with social distancing efforts, visitors were no longer allowed in the hospital. This meant a lot of things, including that previous Family Waiting Rooms could be repurposed as work rooms for newly forming teams.

6/ Visiting Rounds. Members of the team (physicians, nursing, respiratory, etc) joined rounds the wk prior in RICU to learn the workflow & challenges in COVID care. Seasoned front-line providers began codifying their observations for candid discussions: http://www.med.umich.edu/surgery/mcccn/ 

7/ Standardizing Care Pathways. Because of previous experience with ARDS and H1N1 (and now in the RICU), many experts across the system banded together and quickly created standardized protocols. They’re updated often and all open-sourced here: http://www.med.umich.edu/surgery/mcccn/ 

8/ Leveraging the Electronic Medical Record. To make established guidelines easier to follow and implement, standardized COVID order sets were created within the EMR for both floor and ICU patients. To reinforce the guidelines, the PDFs were also linked within the EMR.

9/ Visible Pathways. Some content was further prioritized to be placed on the door of each room. Specifically, we focused on vent management, family contact and code status. Families got updated at least daily.

10/ Consistent Contact. Creating a new “service” required a physical space, but it also required an IT one. (We realized that ~2 hrs into it.) A new service pager and first contact were created through our Health IT group to make it easy for nursing & consultants to contact us.

11/ Start Small, Improve, then Scale. While this particular unit could ultimately take 20 COVID Patients, we started with 2. This allowed us to sort the kinks in work flow and establish new local norms. Once sorted, we added more patients.

12/ Minimizing in-Room Time. To limit exposure time in COVID rooms, procedures (A-lines, central lines, etc) were bundled & performed by a senior at once. Extra supplies & a runner were close by to minimize in/out of the room travel. (We created line carts to mirror those in ICU)

13/ Prophylaxis Rounds. There was a learning curve & some anxiety for everyone involved. To help soften that, we made in person check-ins, multiple time a shift w/ nursing & respiratory therapy to clarify plans, get feedback, clean-up orders & preempt problems later in the day.

14/ COVID Provider Rounds. During this same week, others (Sarah, Charlie, Heidi!) were also scaling up to ICU level COVID capacity. We stayed in contact & leaned on each other often for help, particularly w/ multiple concurrent admissions or challenging patients.

15/ There is No Emergency in a Pandemic.(Ref: https://acanticleforlazarus.com/2020/03/23/there-is-no-emergency-in-a-pandemic/) We tried to keep this central, leaving it up on teaching boards. When we took signout from another provider, it always started w/, “Holding up okay? Do you need anything?...Ok, tell me about the patient..”

16/ The patient you can’t talk to. Perhaps what was hardest about this week was that we couldn’t talk to them (all intubated). I wish I saw this advice sooner to keep humanizing them from @LungDocDoug via @Iwashyna . Will do it going forward. https://twitter.com/iwashyna/status/1247279983074127877?s=20

16/ Ice Cream and Sunrises. The shifts were long and draining. We all found our own fix to look forward to at the end. For me it was post-call ice cream breakfast and walking outside at sunrise the long way to my car.

17/ Thankful for this Team – their energy and enthusiasm that’s visible through masks made this week memorable for the ages. #GoBlue
(Thanks @JocelineVu for the new Michigan Cap!)