Anatomy of an ICU: Why it's so hard for Manitoba to add ICU beds for the sickest COVID-19 patients

In the first seven months of the pandemic, the number of Manitoba patients infected with COVID-19 admitted to intensive care units never crept into the double digits. For weeks at a time, not a single patient with the illness caused by the novel coronavirus occupied an ICU bed.

Beginning in late October, however, that number began a rapid rise, quadrupling to more than 40 patients in less than four weeks.

Health-care workers warned that the units caring for patients with the most severe illnesses would be overwhelmed. If hospitals couldn't find more space, they feared they could soon face heartbreaking choices about who would get care and who would not.

In early November, the province rolled out a three-phase plan that would more than double the number of ICU beds, from 72 to 173, if needed.

Adding those beds requires more than simply making space to put the patients, according to critical-care physicians and health-care officials who spoke with CBC News.

Behind each COVID-19 patient in an intensive care unit stands a team providing round-the-clock care, with a pile of specialized equipment.

The number of beds open to intensive care patients in Manitoba has increased to more than 100, and COVID-19 patients regularly make up roughly half of the patient population in those units.

"To staff these additional beds ... we are relying on staff and physicians who normally work in other areas to support these high-demand areas," Manitoba Shared Health Chief Nursing Officer Lanette Siragusa said at a Nov. 18 news conference.

The plan involves creating teams, led by nurses, that include a wide range of health-care workers, many of whom may never have worked in an ICU before. 

Other provinces and countries have increased ICU capacity using mobile units, but these are typically staffed by workers trained for those environments, said the president of the Canadian Federation of Nurses Unions.

"What Manitoba is suggesting is something we've never seen before," said Linda Silas.

[Redeployed workers are] going to freak out. They're going to be scared, going to an ICU.- Patricia Tamlin, ICU nurse in Toronto

For the health-care professionals pulled into working in an ICU for a first time, the experience could come as a shock, said Patricia Tamlin, an ICU nurse in Toronto with 40 years of experience.

"It's overwhelming. It's noisy. It's loud," said Tamlin. "It can be fast-paced. You're in PPE that is very different. They may be assigned a ventilated patient — they've maybe never seen a person on a ventilator."

'The sickest patients'

In a normal year, Manitoba ICUs take care of around 5,000 patients, according to Shared Health, the authority responsible for co-ordinating health care in the province.

"ICUs are places in hospitals to take care of the sickest patients," said Dr. Allan Garland, an ICU physician and co-head of the critical care medicine section of the University of Manitoba's college of medicine.

The vast majority of COVID-19 patients admitted to an ICU — around 95 per cent — will either be on the verge of respiratory failure so severe they need to be put on a medical ventilator, or already need ventilation, said infectious disease expert Dr. Anand Kumar.

The experience of being on a ventilator is "extremely unpleasant" and can even be traumatic, said Kumar, an intensive care unit physician at Health Sciences Centre.

"You have to basically sedate the heck out of them to the point that they're almost in a coma, or sometimes you have to put them in a full coma and pharmacologically paralyze them."

A tube is inserted into the patient's mouth, down their trachea and into their lungs. Then the machine pumps in highly concentrated oxygen, while forcing the lungs to expand and contract.

The disease doesn't only affect the lungs. 

"COVID is associated with problems in multiple organ systems," Garland said, including the heart and gastrointestinal systems.

'The whole gamut of people'

Caring for these patients requires a range of medical staff support.

Normally, there would be one critical care nurse for each ICU patient at all times, with a critical care physician for every four to eight patients, Kumar said.

But beyond that, "You need the whole gamut of people that work in hospitals to take care of these patients, and many of them are highly specialized," said Garland.

ICU physicians need access to specialists in various fields, including surgery, anesthesiology, cardiology, nephrology (kidneys), and gastroenterology. ICUs also need pharmacists, dietitians, nursing assistants and cleaners. 

In addition, ICUs need respiratory therapists to operate the ventilators — approximately one for every eight patients. 

As Manitoba health leaders expand the number of ICU beds, they've been forced to pull in staff from all corners of the health system. They have offered training to family physicians and redeployed nurses who have completed critical care training and now work in other fields.

The province is working to implement a team-based model that would enable critical care nurses to care for more than one patient at a time. These teams include "nurse extenders" — often ward nurses who haven't completed a six-month critical-care nursing program offered through the WRHA — as well as respiratory therapists, physiotherapists and other support staff.

"By identifying the tasks that other health-care workers are able to support, the critical-care nurses are able to support the most specialized care needs of more than one patient," said a spokesperson for Shared Health.

Tamlin, the ICU nurse in Toronto, worries about the impact this could have on the care each patient receives. ICU nurses receive specialized training to do things like interpreting wave signatures on a heart monitor, or increasing and decreasing specialized medications. 

"Now, if you have me watching three critically ill patients, I'm not only watching after the patients. I'm also going to be trying to monitor these staff of various expertise, coming from various places," she said.

Space and power

Patients with lesser needs can be moved to other areas of the hospital not traditionally used for medical care, or even to sites outside the hospital. The same is not true for ICU patients.

"You need a special space that's been designed or adapted for the mechanical needs, the equipment that needs to be there," Kumar said.

The rooms need to be big enough to fit all that equipment.

ICU beds are larger than typical hospital beds, in order to safely accommodate a sedated patient hooked up to a variety of complex equipment. That includes banks of monitors such as echocardiograms (heart monitors), blood pressure monitors and electroencephalograms (brain activity monitors).

Patients may need continuous low-intensity dialysis, requiring another bulky piece of equipment.

The rooms also need medical gas pumped in through outlets connected to large tanks outside the hospital, suction machines to clear airways and numerous IV poles for the medications needed to keep patients alive. 

To power all of this equipment, each bed needs a number of electrical outlets — more than an average hospital room would have. 

All of that limits which spaces can be converted to ICU beds, leaving operating rooms and post-op recovery rooms among the few options. Hundreds of procedures have been postponed, and more simply aren't being scheduled, so these spaces can be turned over to intensive care.

Ideally, when treating patients with infectious respiratory diseases, the rooms would have negative-pressure ventilation that continuously sucks air out. 

"Those are at a premium," said Kumar, who estimates that about a quarter of Winnipeg ICU beds are equipped with negative-pressure ventilation under normal circumstances.

Spaces may need to be re-engineered to create negative pressure, he said. Some hospitals have accomplished this using high-efficiency particulate air (HEPA) filters.

Experience matters

Despite the challenges of squeezing more ICU beds into the available space, the province says it has mapped out room to potentially care for over 100 more patients than the system could typically handle. 

Staffing those beds remains the challenge. 

"Even before COVID happened, there were some serious concerns about the supply of ICU nurses. Now, that concern has got to be dramatically increased," Garland said.

Working in an ICU requires extensive training. Before taking the six-month ICU program, nurses need one year of experience in acute care. 

Health officials have repeatedly said no one will be required to do a task that they have not been trained to do.

It remains unclear what the ratio of nurses to patients will look like under the new team-based model. 

Even if nurses receive training to give them the skills needed to work in an ICU, without the years of experience of people like Tamlin, some health workers may still feel unprepared.

"They're going to freak out. They're going to be scared going to an ICU," she said.