Contingency plan for the intensive care services for the COVID-19 pandemic

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"apellidos" => "Trenado Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "n" "identificador" => "aff0070" ] ] ] 18 => array:2 [ "colaborador" => "Junta directiva de la SEMICYUC" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn0005" ] ] ] 19 => array:2 [ "colaborador" => "y Junta directiva de la SEEIUC" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "2" "identificador" => "fn0010" ] ] ] ] "afiliaciones" => array:14 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Área de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Área de Críticos, Corporación Sanitaria i Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Sabadell, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Medicina Intensiva y Urgencias, Hospital San Juan de Dios de Córdoba, Córdoba, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital de Torrejón, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Clínic de Barcelona, Barcelona, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "División de Terapia Intensiva, Hospital Juan A. Fernández, Buenos Aires, Argentina" "etiqueta" => "k" "identificador" => "aff0055" ] 11 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain" "etiqueta" => "l" "identificador" => "aff0060" ] 12 => array:3 [ "entidad" => "Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "m" "identificador" => "aff0065" ] 13 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain" "etiqueta" => "n" "identificador" => "aff0070" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19" ] ] "textoCompleto" => "IntroductionOn 7 January 2020, the Chinese authorities identified a new virus belonging to the family Coronaviridae as the cause of an outbreak of pneumonia cases in the city of Wuhan, in the province of Hubei. The virus was subsequently referred to as SARS-CoV-2, and the disease it causes became known as COVID-19.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>According to data from the European Center for Disease Prevention and Control (ECDC), between 31 December 2019 and 16 March 2020, the disease had spread to 139 countries, with the declaration of 16,741 cases, including 6507 deaths.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>In Spain, information from the Ministry of Health indicated that at 13:00 h on 16 March there were 9191 positive cases in the country, of which 432 corresponded to patients admitted to Intensive Care Unit (ICUs).<a class="elsevierStyleCrossRef" href="#bib0015">3</a>In this scenario, the scientific societies SEMICYUC, representing specialists in Intensive Care Medicine, and the SEEIUC, representing nursing professionals dedicated to critical patient care, contemplated the need to develop a contingency plan to address the demands associated with this new disease, with the following objectives in mind:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1To provide the health authorities and managing bodies and clinicians with a technical document addressing all aspects related to identification of the healthcare needs of seriously ill patients in the face of the pandemic caused by the new SARS-CoV-2 virus, with a view to allowing integral and realistic planning of the Departments of Intensive Care Medicine at national and regional level, and in each hospital.</li><li class="elsevierStyleListItem" id="lsti0010">2To ensure optimum care of seriously ill COVID-19 patients and of other critical patients with other disease conditions.</li><li class="elsevierStyleListItem" id="lsti0015">3To limit the nosocomial spread of COVID-19 in order to:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">oProtect the healthcare and non-healthcare staff in all the ICUs.</li><li class="elsevierStyleListItem" id="lsti0025">oPrevent hospitals from amplifying the disease.</li><li class="elsevierStyleListItem" id="lsti0030">oProtect non-COVID-19 patients from becoming infected, with a view to maintaining the capacity to provide essential medical care for those not affected by COVID-19.</li></ul></li><li class="elsevierStyleListItem" id="lsti0035">4To optimize the human resources of the Departments of Intensive Care Medicine.</li><li class="elsevierStyleListItem" id="lsti0040">5To designate limited medical care resources in a rational, ethical and organized manner, with a view to affording the greatest possible benefit for the greatest possible number of people.</li></ul>Previsions for the COVID-19 pandemicThe planning of possible scenarios is based on the use of FluSurge 2.0. This software was developed by the Centers for Disease Control and Prevention (CDC), and offers a free access spreadsheet to perform approximate calculations of the service demands in situations of a moderate to severe pandemic.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> The tool allows us to modify the population at risk, the available hospital resources and the assumptions referred to the epidemiologic course of the pandemic—yielding an approximate estimate of the needs in that context. Accordingly, the programme estimates the number of hospital admissions and deaths, the number of hospitalized persons, the number of patients requiring admission to the ICU, the number of these individuals who require mechanical ventilation, and the degree of saturation of the available services for dealing with these patients.It is important to mention that FluSurge 2.0 was specifically designed to consider the possible effect of an influenza virus pandemic, and has only been validated in that context. Its application to the COVID-19 pandemic must be assessed with caution.The calculation of the possible scenarios requires a series of initial assumptions regarding the characteristics of the pandemic. The estimates used are based on the published series corresponding to the Chinese outbreak,<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a> the Italian experience with the disease,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> and the experience gained from influenza virus H1N1.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>The assumptions were a mean hospital stay of 11 days, a mean ICU stay of 14 days, 11% of hospitalized patients requiring admission to the ICU, and 6.5% requiring mechanical ventilation.Considering an attack rate (proportion of people within a population who suffer contagion by a given disease) of 35% and a duration of the pandemic of 12 weeks (data which are adjusted to the evolution of the most severely affected Spanish Autonomous Communities), the following is contemplated:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045">o278,435 hospital admissions in 12 weeks.</li><li class="elsevierStyleListItem" id="lsti0050">oPeak demand in week 7.</li><li class="elsevierStyleListItem" id="lsti0055">oNeed for over 9000 ICU beds in the moments of greatest demand.</li><li class="elsevierStyleListItem" id="lsti0060">oNeed for over 5000 respirators in the weeks of greatest demand.</li></ul>The contemplated scenario is conceived to plan the needs in the event the containment measures are insufficient. The following is recommended:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065">oPlanning according to the actual situation in each moment.</li><li class="elsevierStyleListItem" id="lsti0070">oReassessment of the evolution in response to the containment measures.</li></ul>Pandemic response phasesIt is advisable to adjust the response according to the evolution of the pandemic.<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a>Phase 0. Preparation<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075">oNormal care activity.</li><li class="elsevierStyleListItem" id="lsti0080">oDevelopment of protocols and contingency plan.</li><li class="elsevierStyleListItem" id="lsti0085">oStudy of the availability of beds.</li><li class="elsevierStyleListItem" id="lsti0090">oPrevision of equipment.</li><li class="elsevierStyleListItem" id="lsti0095">oStaff training.</li></ul>Phase 1. Start of the pandemic<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0100">oCancelation of elective surgeries.</li><li class="elsevierStyleListItem" id="lsti0105">oPreparation of additional spaces as ICU beds.</li><li class="elsevierStyleListItem" id="lsti0110">oFull staffing. Release from out-ICU activities.</li><li class="elsevierStyleListItem" id="lsti0115">oSectorization of work teams.</li></ul>Phase 2. Saturation of the ICU<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0120">oSuspension of all elective activity.</li><li class="elsevierStyleListItem" id="lsti0125">oOrganization of shifts.</li><li class="elsevierStyleListItem" id="lsti0130">oSectorization of patients with COVID-19.</li><li class="elsevierStyleListItem" id="lsti0135">oStrict admission criteria.</li></ul>Phase 3. Collapse of the ICU and of the hospital<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0140">oPrioritize the care of patients most likely to recover.</li><li class="elsevierStyleListItem" id="lsti0145">oNurse-to-patient ratio according to availability.</li><li class="elsevierStyleListItem" id="lsti0150">oPrioritize general benefit over particular benefit.</li></ul>Human and technical resource requirementsCoronavirus committeesCoronavirus committees are working groups at national, regional and local level (pertaining to the hospital) that prepare the necessary resources and action plans in the face of all the possible scenarios.The committees have the following objectives:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0155">oDefine and agree the contingency plan with the administration.</li><li class="elsevierStyleListItem" id="lsti0160">oGuarantee acquisition of the material.</li><li class="elsevierStyleListItem" id="lsti0165">oEstablish the necessary protocols.</li><li class="elsevierStyleListItem" id="lsti0170">oPlan the spaces.</li><li class="elsevierStyleListItem" id="lsti0175">oDefine transfer procedures.</li><li class="elsevierStyleListItem" id="lsti0180">oOrganize the working teams.</li></ul>The role of the intensivist in the committees is essential for:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0185">oPreparing the critical patient care areas and circuits.</li><li class="elsevierStyleListItem" id="lsti0190">oDefining circuits for in- and out-hospital transfer.</li><li class="elsevierStyleListItem" id="lsti0195">oInforming of the situation and needs in the ICU.</li></ul>Technical resourcesThe following recommendations are made:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0200">oCritical patients with COVID-19 are to be treated in an ICU by specialists in Intensive Care Medicine.</li><li class="elsevierStyleListItem" id="lsti0205">oEach ICU box or space must be equipped with a ventilator for advanced invasive ventilation.</li><li class="elsevierStyleListItem" id="lsti0210">oThere must be a transfer ventilator for every 10 patients.</li><li class="elsevierStyleListItem" id="lsti0215">oAll these aspects must be taken into account when generating extraordinary ICU spaces in other areas of the hospital.</li><li class="elsevierStyleListItem" id="lsti0220">oIt is advisable to maintain grouping and isolation by cohorts.</li><li class="elsevierStyleListItem" id="lsti0225">oGrouping by cohorts should prevail over the concept of rooms with closed doors.</li><li class="elsevierStyleListItem" id="lsti0230">oIf an ICU has open and closed boxes, it is advisable to initially use the closed boxes.</li><li class="elsevierStyleListItem" id="lsti0235">oIf necessary, the physical space of the ICU should be expanded.</li></ul>Human resourcesEach center requires a care modification plan contemplating the distribution of workloads, care responsibilities and working hours or shifts.The following is recommended in reference to intensivists<a class="elsevierStyleCrossRef" href="#bib0055">11</a>:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0240">oNormal work shift:<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0245">-An intensivist for every three patients.</li><li class="elsevierStyleListItem" id="lsti0250">-In the event of saturation, other non-intensivist physicians (including residents in training) may be incorporated, coordinated by an intensivist.</li></ul></li><li class="elsevierStyleListItem" id="lsti0255">oDuty shift:<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0260">-Two intensivists or an intensivist plus a fourth- or fifth-year resident for every 12 beds.</li><li class="elsevierStyleListItem" id="lsti0265">-In the event of saturation, other non-intensivist physicians (including residents in training) may be incorporated, coordinated by an intensivist.</li></ul></li></ul>The following is recommended in reference to nursing staff<a class="elsevierStyleCrossRef" href="#bib0060">12</a>:<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0270">oA nursing professional per shift for every two critical patients.</li><li class="elsevierStyleListItem" id="lsti0275">oReinforcement with one nurse for every 4–6 beds as support in moments of maximum workload (prone positioning, intubation, transfers, etc.).</li><li class="elsevierStyleListItem" id="lsti0280">oA nursing assistant (NA) for every 4 beds.</li><li class="elsevierStyleListItem" id="lsti0285">oReinforcement per shift for every 8–12 beds for organization and cleaning of material, support and replacement.</li></ul>Staff training<a class="elsevierStyleCrossRef" href="#bib0045">9</a><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0290">oThe SEMICYUC will generate training material: charts, diagrams, posters, etc.</li><li class="elsevierStyleListItem" id="lsti0295">oEach hospital should organize training sessions with at least the following contents:<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0300">-Epidemiology of COVID-19.</li><li class="elsevierStyleListItem" id="lsti0305">-Impact upon activity.</li><li class="elsevierStyleListItem" id="lsti0310">-Transmission.</li><li class="elsevierStyleListItem" id="lsti0315">-Diagnosis of COVID-19.</li><li class="elsevierStyleListItem" id="lsti0320">-Personal protection measures: personal protective equipment (PPE), procedures and isolation.</li></ul></li></ul>Internal communication. Transmission of informationWe recommend the following<a class="elsevierStyleCrossRef" href="#bib0065">13</a>:<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0325">oDefinition of an information transmission protocol.</li><li class="elsevierStyleListItem" id="lsti0330">oAvoid close contact during the transmission of information.</li><li class="elsevierStyleListItem" id="lsti0335">oTake special care in transmitting the therapeutic plan and the anticipation of changes.</li><li class="elsevierStyleListItem" id="lsti0340">oUse structured transmission, for example based on SBAR (Situation-Background-Assessment-Recommendation).</li><li class="elsevierStyleListItem" id="lsti0345">oAdequate completion the patient clinical history.</li></ul>Communication with and information for patients and relatives<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0350">oIn those ICUs with cases of COVID-19, it is advisable for the families of all the admitted patients to be informed of the fact on a daily basis, as well as of the moment in which there no longer are any such cases—without providing any other type of information that may affect the intimacy of such patients and their families.</li><li class="elsevierStyleListItem" id="lsti0355">oIn those ICUs with cases of COVID-19, it is advisable for the families of the admitted patients to receive the usual daily information from the team outside the Unit.</li><li class="elsevierStyleListItem" id="lsti0360">oThe patients with COVID-19 are to be isolated, with absolute restriction of accompaniment/visits. Only in situations analyzed on an individualized basis by the medical team, due to strict necessity (e.g., in imminent death situations) or based on other clinical, ethical and/or humane considerations, will limited, controlled, brief and supervised visits be allowed, after instructing the relatives on how to wear and remove the PPE, with due help and supervision.</li><li class="elsevierStyleListItem" id="lsti0365">oThe families are to be advised to minimize patient accompaniment as far as possible, regardless of whether the patient has COVID-19 or not.</li><li class="elsevierStyleListItem" id="lsti0370">oVisits to patients without COVID-19 in Units where COVID-19 cases are present are to be adapted to the architectural characteristics of the Unit.</li></ul>Optimized use of resourcesCoronavirus is mainly transmitted by respiratory droplets measuring over 5 μm in size and through direct contact with the secretions of infected individuals. It may also be transmitted by the aerosols produced during therapeutic procedures. We therefore recommend the following<a class="elsevierStyleCrossRefs" href="#bib0070">14–17</a>:<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0375">oThe precautions for the treatment of all patients under study as probable cases or with confirmed infection must include the standard measures referred to contact and the transmission of droplets.</li><li class="elsevierStyleListItem" id="lsti0380">oStrict hand hygiene is mandatory.</li><li class="elsevierStyleListItem" id="lsti0385">oAll the professionals must be trained in the use of PPE.</li><li class="elsevierStyleListItem" id="lsti0390">oIdeally, the patients should remain isolated in an individual room, and if possible under negative pressure.</li><li class="elsevierStyleListItem" id="lsti0395">oPriority should be placed on patient grouping (cohorting) in a specific area.</li><li class="elsevierStyleListItem" id="lsti0400">oThe generated waste is regarded as class III waste.</li><li class="elsevierStyleListItem" id="lsti0405">oThe PPE is to be removed within the box, except for the respiratory and eye protection.</li><li class="elsevierStyleListItem" id="lsti0410">oThe clothing and utensils require no special treatment.</li></ul>Personal protective equipmentSuch equipment must include<a class="elsevierStyleCrossRef" href="#bib0070">14</a>:<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0415">oProtective clothing and gloves.</li><li class="elsevierStyleListItem" id="lsti0420">oRespiratory protection.</li><li class="elsevierStyleListItem" id="lsti0425">oProtection of the eyes and face.</li></ul>The following recommendations are made with regard to respiratory protection<a class="elsevierStyleCrossRefs" href="#bib0070">14,16</a>:<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0430">oPatients with confirmed infection and cases under investigation should wear surgical masks, if possible.</li><li class="elsevierStyleListItem" id="lsti0435">oUse two high efficacy antimicrobial filters (inspiratory and expiratory arms) in the case of invasive mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0090">18</a></li><li class="elsevierStyleListItem" id="lsti0440">oUse closed aspiration systems.</li><li class="elsevierStyleListItem" id="lsti0445">oIn the case of noninvasive ventilation, it is advisable to use antiviral filters and preferably double tubing equipment.</li><li class="elsevierStyleListItem" id="lsti0450">oAvoid manual ventilation with bag mask. If done, use a high efficacy antimicrobial filter.</li><li class="elsevierStyleListItem" id="lsti0455">oAvoid active humidification, aerosol therapy and circuit disconnections.<a class="elsevierStyleCrossRef" href="#bib0090">18</a></li><li class="elsevierStyleListItem" id="lsti0460">oWhen entering the room, or within a perimeter of 2 m from the patient, if aerosol-generating procedures are not going to be carried out, it is advisable to wear<a class="elsevierStyleCrossRef" href="#bib0075">15</a>:<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0465">-A gown (disposable paper gowns are allowed).</li><li class="elsevierStyleListItem" id="lsti0470">-Mask (surgical mask or FFP2 if available, and always ensuring the existence of a sufficient stock).</li><li class="elsevierStyleListItem" id="lsti0475">-Gloves.</li><li class="elsevierStyleListItem" id="lsti0480">-Anti-splash safety goggles.</li></ul></li><li class="elsevierStyleListItem" id="lsti0485">oIf an aerosol-generating procedure is to be carried out, it is advisable to wear<a class="elsevierStyleCrossRefs" href="#bib0080">16,18</a>:<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0490">-An FFP2mask or preferably FFP3 mask, if available.</li><li class="elsevierStyleListItem" id="lsti0495">-Adjusted integral eye protection or complete face mask.</li><li class="elsevierStyleListItem" id="lsti0500">-Gloves.</li><li class="elsevierStyleListItem" id="lsti0505">-Impermeable long-sleeved gown.</li></ul></li><li class="elsevierStyleListItem" id="lsti0510">oThe current recommendation is to use the mask only once. Although clear evidence is lacking, in the event of a scarcity of masks, they can be reused by the same professional for a maximum of 8 h of continuous or intermittent activity. Extended use of the mask is allowed provided it is not stained or humid.<a class="elsevierStyleCrossRef" href="#bib0095">19</a></li></ul>Optimization of PPE useRational PPE use is required, with minimization of the exposure times. The following recommendations are made in this regard:<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0515">oPromote recording, control and monitoring measures that do not require entering the room of the patient.</li><li class="elsevierStyleListItem" id="lsti0520">oPlan the tasks and remain in the room as briefly as possible.</li><li class="elsevierStyleListItem" id="lsti0525">oGroup those tasks requiring entry to the box.</li><li class="elsevierStyleListItem" id="lsti0530">oAdjust the perfusions to make the changes during scheduled entry to the box.</li><li class="elsevierStyleListItem" id="lsti0535">oPerform care, explorations, etc., with the fewest persons possible.</li><li class="elsevierStyleListItem" id="lsti0540">oAvoid per protocol aspiration.</li><li class="elsevierStyleListItem" id="lsti0545">oUnify sampling to avoid unnecessary entries.<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0550">-Prepare the sample for transport in the box.</li><li class="elsevierStyleListItem" id="lsti0555">-Clean the outer part of the tube with surface disinfectant or a small towel impregnated with disinfectant.</li><li class="elsevierStyleListItem" id="lsti0560">-Sample transport is to be done personally, avoiding transport systems such as pneumatic tubes.</li></ul></li><li class="elsevierStyleListItem" id="lsti0565">oThe professionals in charge of the patient must supervise any intervention upon the patient by staff not belonging to the Unit.</li></ul>Indications of admission to the ICU in patients with SARS-CoV-2 pneumoniaGeneral criteria for admission to the ICUWe recommend the use of objective ICU admission criteria based on the recommendations of the American Thoracic Society (ATS), the Infectious Diseases Society of America (IDSA)<a class="elsevierStyleCrossRef" href="#bib0100">20</a> and the recent evidence of the analysis of the SARS-CoV-2 (COVID-19) epidemic in China<a class="elsevierStyleCrossRef" href="#bib0105">21</a> (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Admission to the ICU is to be considered in the presence of one major criterion or three or more minor criteria.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Optimization in case of saturation<ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0570">oIn cases of saturation or overwhelming workload, priority must center on those patients most likely to recover.</li><li class="elsevierStyleListItem" id="lsti0575">oThe ICU triage or screening protocols referred to pandemics should only be activated if the ICU resources in a large geographic area have become or are going to become overwhelmed despite all reasonable efforts to expand resources or obtain additional resources.</li><li class="elsevierStyleListItem" id="lsti0580">oIt is essential to have guidelines on the adequacy of therapeutic effort.</li></ul>Inclusion/exclusion criteria<a class="elsevierStyleCrossRefs" href="#bib0110">22–25</a><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0585">oA screening instrument capable of objectively classifying the patients is advised.</li><li class="elsevierStyleListItem" id="lsti0590">oWhile not validated, the only measure proposed to date is based on the use of the SOFA score.<a class="elsevierStyleCrossRef" href="#bib0110">22</a></li><li class="elsevierStyleListItem" id="lsti0595">oFollowing the first assessment, the patients are to be re-evaluated on days 2 and 5, which is when reclassification may be made.</li><li class="elsevierStyleListItem" id="lsti0600">oThe following are exclusion criteria for admission:<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0605">-Poor prognosis despite admission to the ICU.</li><li class="elsevierStyleListItem" id="lsti0610">-Need for resources that cannot be provided.</li><li class="elsevierStyleListItem" id="lsti0615">-Failure to meet severity criteria.</li></ul></li><li class="elsevierStyleListItem" id="lsti0620">oApplication can be made of the specific recommendations on admission exclusion referred to mass casualty events.<a class="elsevierStyleCrossRef" href="#bib0125">25</a></li></ul>Expansion planThe expansion plan includes the transformation and preparation of additional spaces for the care of critical patients in situations of ICU bed collapse, as well as an increase in the number of staff members with expertise in the care of critical patients.Expansion of the departments of intensive care medicineThe possible locations for the stay of critical patients must be equipped with<a class="elsevierStyleCrossRefs" href="#bib0110">22,26,27</a>:<ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0625">oMedicinal gases.</li><li class="elsevierStyleListItem" id="lsti0630">oRespirators for invasive and noninvasive mechanical ventilation.</li><li class="elsevierStyleListItem" id="lsti0635">oPossibility of high-flow oxygen therapy.</li><li class="elsevierStyleListItem" id="lsti0640">oPossibility of advanced monitoring.</li><li class="elsevierStyleListItem" id="lsti0645">oPossibility of continuous extrarenal replacement therapy techniques.</li><li class="elsevierStyleListItem" id="lsti0650">oPoints for hand hygiene.</li><li class="elsevierStyleListItem" id="lsti0655">oAvailability of central monitoring (telemetry) would be desirable.</li></ul>On an orientative basis, the spaces that can be used to expand the number of ICU beds are<a class="elsevierStyleCrossRef" href="#bib0140">28</a>:<ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0660">oIntermediate care units attended by intensivists: the nurse-to-patient ratios must be adjusted to those of a conventional ICU.</li><li class="elsevierStyleListItem" id="lsti0665">oResuscitation units and post-anesthesia recovery units. Scheduled surgery must be suspended. The patients are to be attended by intensivists.</li><li class="elsevierStyleListItem" id="lsti0670">oCritical care or intermediate care areas of the emergency rooms.</li><li class="elsevierStyleListItem" id="lsti0675">oHabilitation of space close to the ICU, with new provision of equipment.</li><li class="elsevierStyleListItem" id="lsti0680">oTransformation of conventional hospitalization areas, day hospitals or ambulatory major surgery areas.</li><li class="elsevierStyleListItem" id="lsti0685">oIn the event of oversaturation, transfer to another center with available space must be considered.</li></ul>If 100% saturation of the Departments of Intensive Care Medicine is anticipated, we recommend centralization of the resources, with:<ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0690">oDevelopment of an inter-hospital transfer protocol.</li><li class="elsevierStyleListItem" id="lsti0695">oCreation in each Autonomous Community of a critical patients coordinator for the integral management of all critical care beds in each Community.</li></ul>Staff expansionWe recommend the following<a class="elsevierStyleCrossRefs" href="#bib0145">29,30</a>:<ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0700">oEstablish a census of all specialists in Intensive Care Medicine, including also:<ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0705">-Physicians with on-duty contracts.</li><li class="elsevierStyleListItem" id="lsti0710">-Intensivists dedicated to other tasks within the hospital.</li><li class="elsevierStyleListItem" id="lsti0715">-Unemployed physicians.</li><li class="elsevierStyleListItem" id="lsti0720">-Newly retired physicians.</li></ul></li><li class="elsevierStyleListItem" id="lsti0725">oEstablish a census of other staff physicians or residents that may be able to care for less seriously ill patients, coordinated by the Department of Intensive Care Medicine.</li><li class="elsevierStyleListItem" id="lsti0730">oProlong substitution contracts.</li><li class="elsevierStyleListItem" id="lsti0735">oEstablish a plan for physician staff provision and distribution of workloads in all the hospitals.</li><li class="elsevierStyleListItem" id="lsti0740">oEstablish a census of the nursing staff with knowledge and experience in the care of critical patients.</li><li class="elsevierStyleListItem" id="lsti0745">oDevelop a plan for the reallocation of experienced nursing staff towards critical care areas.</li><li class="elsevierStyleListItem" id="lsti0750">oTake into account the previsions referred to peak care burden.</li><li class="elsevierStyleListItem" id="lsti0755">oIf medical or nursing staff members that do not carry out their regular work in critical care become necessary, they should receive prior training.</li><li class="elsevierStyleListItem" id="lsti0760">oSuch training should focus on two main areas: intensive care medicine or nursing and control of infections.</li></ul>TransfersInter-hospital transfer<ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0765">oStaff required: attending physician, attending nurse and emergency care technician.</li><li class="elsevierStyleListItem" id="lsti0770">oThe adequate PPE for the attending staff is that recommended for situations of aerosol generation risk.</li><li class="elsevierStyleListItem" id="lsti0775">oTo be taken into account during transfer:<ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0780">-Isolation of the staff in charge of driving the transfer vehicle.</li><li class="elsevierStyleListItem" id="lsti0785">-The relatives cannot travel with the transfer vehicle.</li><li class="elsevierStyleListItem" id="lsti0790">-Limitation of the number of caregivers in the transfer vehicle.</li></ul></li></ul>Intra-hospital transfer<ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0795">oA transfer circuit protocol is to be established: itinerary, elevator, number of intervening persons, PPE.</li><li class="elsevierStyleListItem" id="lsti0800">oSteps for transfer:<ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0805">1Inform the receiving Department, cleanliness and safety.</li><li class="elsevierStyleListItem" id="lsti0810">2Prepare the material.</li><li class="elsevierStyleListItem" id="lsti0815">3Use PPE.</li><li class="elsevierStyleListItem" id="lsti0820">4Notify the receiving Department of the start of transfer.</li><li class="elsevierStyleListItem" id="lsti0825">5Block the elevator for transfer and disinfection.</li><li class="elsevierStyleListItem" id="lsti0830">6Security staff with surgical masks are to precede the team to clear the zone.</li><li class="elsevierStyleListItem" id="lsti0835">7Disinfection of the zones of transfer.</li><li class="elsevierStyleListItem" id="lsti0840">8Return.</li></ul></li></ul>Conflicts of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1368770" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1258218" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1368769" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1258219" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Previsions for the COVID-19 pandemic" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Pandemic response phases" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Phase 0. Preparation" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Phase 1. Start of the pandemic" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Phase 2. Saturation of the ICU" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Phase 3. Collapse of the ICU and of the hospital" ] ] ] 7 => array:3 [ "identificador" => "sec0040" "titulo" => "Human and technical resource requirements" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Coronavirus committees" ] 1 => array:3 [ "identificador" => "sec0050" "titulo" => "Technical resources" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0055" "titulo" => "Human resources" ] ] ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Staff training" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Internal communication. Transmission of information" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Communication with and information for patients and relatives" ] 5 => array:2 [ "identificador" => "sec0075" "titulo" => "Optimized use of resources" ] 6 => array:3 [ "identificador" => "sec0080" "titulo" => "Personal protective equipment" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Optimization of PPE use" ] ] ] 7 => array:3 [ "identificador" => "sec0090" "titulo" => "Indications of admission to the ICU in patients with SARS-CoV-2 pneumonia" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "General criteria for admission to the ICU" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Optimization in case of saturation" ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "Inclusion/exclusion criteria" ] 3 => array:2 [ "identificador" => "sec0110" "titulo" => "Expansion plan" ] 4 => array:2 [ "identificador" => "sec0115" "titulo" => "Expansion of the departments of intensive care medicine" ] 5 => array:2 [ "identificador" => "sec0120" "titulo" => "Staff expansion" ] ] ] 8 => array:3 [ "identificador" => "sec0125" "titulo" => "Transfers" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0130" "titulo" => "Inter-hospital transfer" ] 1 => array:2 [ "identificador" => "sec0135" "titulo" => "Intra-hospital transfer" ] ] ] ] ] 8 => array:2 [ "identificador" => "sec0140" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-21" "fechaAceptado" => "2020-03-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1258218" "palabras" => array:4 [ 0 => "Coronavirus" 1 => "COVID-19" 2 => "SARS-CoV-2" 3 => "Pandemic" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1258219" "palabras" => array:4 [ 0 => "Coronavirus" 1 => "COVID-19" 2 => "SARS-CoV-2" 3 => "Pandemia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "In January 2020, the Chinese authorities identified a new virus of the Coronaviridae family as the cause of several cases of pneumonia of unknown aetiology. The outbreak was initially confined to Wuhan City, but then spread outside Chinese borders. On 31 January 2020, the first case was declared in Spain. On 11 March 2020, The World Health Organization (WHO) declared the coronavirus outbreak a pandemic. On 16 March 2020, there were 139 countries affected. In this situation, the Scientific Societies SEMICYUC and SEEIUC, have decided to draw up this Contingency Plan to guide the response of the Intensive Care Services. The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources. This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "En enero de 2020 China identificó un nuevo virus de la familia de los Coronaviridae como causante de varios casos de neumonía de origen desconocido. Inicialmente confinado a la ciudad de Wuhan, se extendió posteriormente fuera de las fronteras chinas. En España, el primer caso se declaró el 31 de enero de 2020. El 11 de marzo, la Organización Mundial de la Salud declaró el brote de coronavirus como pandemia. El 16 de marzo había 139 países afectados. Ante esta situación, las Sociedades Científicas SEMICYUC y SEEIUC han decidido la elaboración de este plan de contingencia para dar respuesta a las necesidades que conllevará esta nueva enfermedad. Se pretende estimar la magnitud del problema e identificar las necesidades asistenciales, de recursos humanos y materiales, de manera que los servicios de medicina intensiva del país tengan una herramienta que les permita una planificación óptima y realista con que responder a la pandemia." ] ] "NotaPie" => array:4 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rascado Sedes P, Ballesteros Sanz MA, Bodí Saera MA, Carrasco Rodríguez-Rey LF, Castellanos Ortega Á, Catalán González M, et al. Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19. Med Intensiva. 2020;44:363–370." ] 1 => array:3 [ "etiqueta" => "1" "nota" => "The components of the SEMICYUC Board of Directors appear in <a class="elsevierStyleCrossRef" href="#sec0145">Appendix A</a>." "identificador" => "fn0005" ] 2 => array:3 [ "etiqueta" => "2" "nota" => "The components of the SEEIUC Board of Directors appear in <a class="elsevierStyleCrossRef" href="#sec0150">Appendix B</a>." "identificador" => "fn0010" ] 3 => array:2 [ "etiqueta" => "☆☆" "nota" => "This article is published simultaneously in Medicina Intensiva (https://doi.org/10.1016/j.medin.2020.03.006) and in Enfermería Intensiva (https://doi.org/10.1016/j.enfi.2020.03.001), with the consent of the authors and editors." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:2 [ 0 => array:4 [ "apendice" => "Chairman: Ricard Ferrer Roca. Vice-chairman: Alvaro Castellanos Ortega. Secretary: Josep Trenado Alvarez. Vice-secretary: Virginia Fraile Gutiérrez. Treasurer: Alberto Hernández Tejedor. Chairman of the Scientific Committee: Manuel Herrera Gutiérrez. Vice-chairwoman of the Scientific Committee: Paula Ramírez Galleymore. Representative of the working groups: M. Angeles Ballesteros Sanz. Representative of the Autonomous Societies: Pedro Rascado Sedes. Representative of the physicians in training: Leire López del Oliva Calvo. Previous Chairwoman: Maria Cruz Martín Delgado." "etiqueta" => "Appendix A" "titulo" => "Steering Committee of the SEMICYUC" "identificador" => "sec0145" ] 1 => array:4 [ "apendice" => "Chairwoman: Marta Raurell Torreda. Vice-chairwoman: Miriam del Barrio Linares. Secretary: Marta Romero García. Treasurer: Maria Teresa Ruiz García. Director of the journal: Maria Pilar Delgado Hito. Member of the working groups: Juan José Rodríguez Mondejar. Member of the Industry: Carmen Moreno Arroyo. Member of international relations: Alicia San José Arribas. Research member: Maria Jesus Frade Mera." "etiqueta" => "Appendix B" "titulo" => "Steering Committee of the SEEIUC" "identificador" => "sec0150" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Major criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Septic shock with need for vasoactive amine drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory failure requiring mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minor criteria \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory frequency > 30 rpm with conventional oxygen therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PaO2/FiO2 < 250 with conventional oxygen therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilateral lung infiltrates \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Altered consciousness \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elevation of urea (>20 mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leukopenia (<4000 cells/mL) and lymphocytopenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thrombocytopenia (<100,000/mL) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypothermia (<36 °C) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypotension requiring aggressive therapy with fluids \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">D-dimer > 1 μg/l \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2350925.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Major and minor criteria of admission to the Intensive Care Unit (ICU)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. 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Special article

Contingency plan for the intensive care services for the COVID-19 pandemic

Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19

P. Rascado Sedesa,

Corresponding author

pedrorascado@hotmail.com

Corresponding author.

, M.A. Ballesteros Sanzb, M.A. Bodí Saerac, L.F. Carrasco Rodríguez-Reyd, A. Castellanos Ortegae, M. Catalán Gonzálezd, C. de Haro Lópezf, E. Díaz Santosf, A. Escriba Barcenag, M.J. Frade Merad, J.C. Igeño Canoh, M.C. Martín Delgadoi, G. Martínez Estalellaj, N. Raimondik, O. Roca i Gasl, A. Rodríguez Oviedoc, E. Romero San Píom, J. Trenado Álvarezn, Junta directiva de la SEMICYUC 1, y Junta directiva de la SEEIUC 2

a Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain

b Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain

c Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain

d Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain

e Área de Medicina Intensiva, Hospital Universitario y Politécnico La Fe, Universidad de Valencia, Valencia, Spain

f Área de Críticos, Corporación Sanitaria i Universitaria Parc Tauli, CIBER Enfermedades Respiratorias, Sabadell, Barcelona, Spain

g Servicio de Medicina Intensiva, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain

h Servicio de Medicina Intensiva y Urgencias, Hospital San Juan de Dios de Córdoba, Córdoba, Spain

i Servicio de Medicina Intensiva, Hospital de Torrejón, Torrejón de Ardoz, Madrid, Spain

j Servicio de Medicina Intensiva, Hospital Clínic de Barcelona, Barcelona, Spain

k División de Terapia Intensiva, Hospital Juan A. Fernández, Buenos Aires, Argentina

l Servicio de Medicina Intensiva, Hospital Universitario Vall d'Hebron, Barcelona, Spain

m Hospital Universitario Central de Asturias, Oviedo, Spain

n Servicio de Medicina Intensiva, Hospital Universitario Mútua Terrassa, Terrassa, Barcelona, Spain

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            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "&#193;rea de Cr&#237;ticos&#44; Corporaci&#243;n Sanitaria i Universitaria Parc Tauli&#44; CIBER Enfermedades Respiratorias&#44; Sabadell&#44; Barcelona&#44; Spain"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario de Fuenlabrada&#44; Fuenlabrada&#44; Madrid&#44; Spain"
            "etiqueta" => "g"
            "identificador" => "aff0035"
          ]
          7 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva y Urgencias&#44; Hospital San Juan de Dios de C&#243;rdoba&#44; C&#243;rdoba&#44; Spain"
            "etiqueta" => "h"
            "identificador" => "aff0040"
          ]
          8 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital de Torrej&#243;n&#44; Torrej&#243;n de Ardoz&#44; Madrid&#44; Spain"
            "etiqueta" => "i"
            "identificador" => "aff0045"
          ]
          9 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Cl&#237;nic de Barcelona&#44; Barcelona&#44; Spain"
            "etiqueta" => "j"
            "identificador" => "aff0050"
          ]
          10 => array:3 [
            "entidad" => "Divisi&#243;n de Terapia Intensiva&#44; Hospital Juan A&#46; Ferna&#769;ndez&#44; Buenos Aires&#44; Argentina"
            "etiqueta" => "k"
            "identificador" => "aff0055"
          ]
          11 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario Vall d&#39;Hebron&#44; Barcelona&#44; Spain"
            "etiqueta" => "l"
            "identificador" => "aff0060"
          ]
          12 => array:3 [
            "entidad" => "Hospital Universitario Central de Asturias&#44; Oviedo&#44; Spain"
            "etiqueta" => "m"
            "identificador" => "aff0065"
          ]
          13 => array:3 [
            "entidad" => "Servicio de Medicina Intensiva&#44; Hospital Universitario M&#250;tua Terrassa&#44; Terrassa&#44; Barcelona&#44; Spain"
            "etiqueta" => "n"
            "identificador" => "aff0070"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">On 7 January 2020&#44; the Chinese authorities identified a new virus belonging to the family <span class="elsevierStyleItalic">Coronaviridae</span> as the cause of an outbreak of pneumonia cases in the city of Wuhan&#44; in the province of Hubei&#46; The virus was subsequently referred to as SARS-CoV-2&#44; and the disease it causes became known as COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">According to data from the European Center for Disease Prevention and Control &#40;ECDC&#41;&#44; between 31 December 2019 and 16 March 2020&#44; the disease had spread to 139 countries&#44; with the declaration of 16&#44;741 cases&#44; including 6507 deaths&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Spain&#44; information from the Ministry of Health indicated that at 13&#58;00&#8239;h on 16 March there were 9191 positive cases in the country&#44; of which 432 corresponded to patients admitted to Intensive Care Unit &#40;ICUs&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In this scenario&#44; the scientific societies SEMICYUC&#44; representing specialists in Intensive Care Medicine&#44; and the SEEIUC&#44; representing nursing professionals dedicated to critical patient care&#44; contemplated the need to develop a contingency plan to address the demands associated with this new disease&#44; with the following objectives in mind&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0025" class="elsevierStylePara elsevierViewall">To provide the health authorities and managing bodies and clinicians with a technical document addressing all aspects related to identification of the healthcare needs of seriously ill patients in the face of the pandemic caused by the new SARS-CoV-2 virus&#44; with a view to allowing integral and realistic planning of the Departments of Intensive Care Medicine at national and regional level&#44; and in each hospital&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0030" class="elsevierStylePara elsevierViewall">To ensure optimum care of seriously ill COVID-19 patients and of other critical patients with other disease conditions&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0035" class="elsevierStylePara elsevierViewall">To limit the nosocomial spread of COVID-19 in order to&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">o</span><p id="par0040" class="elsevierStylePara elsevierViewall">Protect the healthcare and non-healthcare staff in all the ICUs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">o</span><p id="par0045" class="elsevierStylePara elsevierViewall">Prevent hospitals from amplifying the disease&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">o</span><p id="par0050" class="elsevierStylePara elsevierViewall">Protect non-COVID-19 patients from becoming infected&#44; with a view to maintaining the capacity to provide essential medical care for those not affected by COVID-19&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4</span><p id="par0055" class="elsevierStylePara elsevierViewall">To optimize the human resources of the Departments of Intensive Care Medicine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">5</span><p id="par0060" class="elsevierStylePara elsevierViewall">To designate limited medical care resources in a rational&#44; ethical and organized manner&#44; with a view to affording the greatest possible benefit for the greatest possible number of people&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Previsions for the COVID-19 pandemic</span><p id="par0065" class="elsevierStylePara elsevierViewall">The planning of possible scenarios is based on the use of FluSurge 2&#46;0&#46; This software was developed by the Centers for Disease Control and Prevention &#40;CDC&#41;&#44; and offers a free access spreadsheet to perform approximate calculations of the service demands in situations of a moderate to severe pandemic&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The tool allows us to modify the population at risk&#44; the available hospital resources and the assumptions referred to the epidemiologic course of the pandemic&#8212;yielding an approximate estimate of the needs in that context&#46; Accordingly&#44; the programme estimates the number of hospital admissions and deaths&#44; the number of hospitalized persons&#44; the number of patients requiring admission to the ICU&#44; the number of these individuals who require mechanical ventilation&#44; and the degree of saturation of the available services for dealing with these patients&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is important to mention that FluSurge 2&#46;0 was specifically designed to consider the possible effect of an influenza virus pandemic&#44; and has only been validated in that context&#46; Its application to the COVID-19 pandemic must be assessed with caution&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The calculation of the possible scenarios requires a series of initial assumptions regarding the characteristics of the pandemic&#46; The estimates used are based on the published series corresponding to the Chinese outbreak&#44;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> the Italian experience with the disease&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and the experience gained from influenza virus H1N1&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The assumptions were a mean hospital stay of 11 days&#44; a mean ICU stay of 14 days&#44; 11&#37; of hospitalized patients requiring admission to the ICU&#44; and 6&#46;5&#37; requiring mechanical ventilation&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Considering an attack rate &#40;proportion of people within a population who suffer contagion by a given disease&#41; of 35&#37; and a duration of the pandemic of 12 weeks &#40;data which are adjusted to the evolution of the most severely affected Spanish Autonomous Communities&#41;&#44; the following is contemplated&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">o</span><p id="par0090" class="elsevierStylePara elsevierViewall">278&#44;435 hospital admissions in 12 weeks&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">o</span><p id="par0095" class="elsevierStylePara elsevierViewall">Peak demand in week 7&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">o</span><p id="par0100" class="elsevierStylePara elsevierViewall">Need for over 9000 ICU beds in the moments of greatest demand&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">o</span><p id="par0105" class="elsevierStylePara elsevierViewall">Need for over 5000 respirators in the weeks of greatest demand&#46;</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">The contemplated scenario is conceived to plan the needs in the event the containment measures are insufficient&#46; The following is recommended&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">o</span><p id="par0115" class="elsevierStylePara elsevierViewall">Planning according to the actual situation in each moment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">o</span><p id="par0120" class="elsevierStylePara elsevierViewall">Reassessment of the evolution in response to the containment measures&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pandemic response phases</span><p id="par0125" class="elsevierStylePara elsevierViewall">It is advisable to adjust the response according to the evolution of the pandemic&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Phase 0&#46; Preparation</span><p id="par0130" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">o</span><p id="par0135" class="elsevierStylePara elsevierViewall">Normal care activity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">o</span><p id="par0140" class="elsevierStylePara elsevierViewall">Development of protocols and contingency plan&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">o</span><p id="par0145" class="elsevierStylePara elsevierViewall">Study of the availability of beds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">o</span><p id="par0150" class="elsevierStylePara elsevierViewall">Prevision of equipment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">o</span><p id="par0155" class="elsevierStylePara elsevierViewall">Staff training&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Phase 1&#46; Start of the pandemic</span><p id="par0160" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">o</span><p id="par0165" class="elsevierStylePara elsevierViewall">Cancelation of elective surgeries&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">o</span><p id="par0170" class="elsevierStylePara elsevierViewall">Preparation of additional spaces as ICU beds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">o</span><p id="par0175" class="elsevierStylePara elsevierViewall">Full staffing&#46; Release from out-ICU activities&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">o</span><p id="par0180" class="elsevierStylePara elsevierViewall">Sectorization of work teams&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Phase 2&#46; Saturation of the ICU</span><p id="par0185" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">o</span><p id="par0190" class="elsevierStylePara elsevierViewall">Suspension of all elective activity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">o</span><p id="par0195" class="elsevierStylePara elsevierViewall">Organization of shifts&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">o</span><p id="par0200" class="elsevierStylePara elsevierViewall">Sectorization of patients with COVID-19&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">o</span><p id="par0205" class="elsevierStylePara elsevierViewall">Strict admission criteria&#46;</p></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Phase 3&#46; Collapse of the ICU and of the hospital</span><p id="par0210" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">o</span><p id="par0215" class="elsevierStylePara elsevierViewall">Prioritize the care of patients most likely to recover&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">o</span><p id="par0220" class="elsevierStylePara elsevierViewall">Nurse-to-patient ratio according to availability&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">o</span><p id="par0225" class="elsevierStylePara elsevierViewall">Prioritize general benefit over particular benefit&#46;</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Human and technical resource requirements</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Coronavirus committees</span><p id="par0230" class="elsevierStylePara elsevierViewall">Coronavirus committees are working groups at national&#44; regional and local level &#40;pertaining to the hospital&#41; that prepare the necessary resources and action plans in the face of all the possible scenarios&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The committees have the following objectives&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">o</span><p id="par0240" class="elsevierStylePara elsevierViewall">Define and agree the contingency plan with the administration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">o</span><p id="par0245" class="elsevierStylePara elsevierViewall">Guarantee acquisition of the material&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">o</span><p id="par0250" class="elsevierStylePara elsevierViewall">Establish the necessary protocols&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">o</span><p id="par0255" class="elsevierStylePara elsevierViewall">Plan the spaces&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">o</span><p id="par0260" class="elsevierStylePara elsevierViewall">Define transfer procedures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">o</span><p id="par0265" class="elsevierStylePara elsevierViewall">Organize the working teams&#46;</p></li></ul></p><p id="par0270" class="elsevierStylePara elsevierViewall">The role of the intensivist in the committees is essential for&#58;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">o</span><p id="par0275" class="elsevierStylePara elsevierViewall">Preparing the critical patient care areas and circuits&#46;</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">o</span><p id="par0280" class="elsevierStylePara elsevierViewall">Defining circuits for in- and out-hospital transfer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">o</span><p id="par0285" class="elsevierStylePara elsevierViewall">Informing of the situation and needs in the ICU&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Technical resources</span><p id="par0290" class="elsevierStylePara elsevierViewall">The following recommendations are made&#58;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">o</span><p id="par0295" class="elsevierStylePara elsevierViewall">Critical patients with COVID-19 are to be treated in an ICU by specialists in Intensive Care Medicine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">o</span><p id="par0300" class="elsevierStylePara elsevierViewall">Each ICU box or space must be equipped with a ventilator for advanced invasive ventilation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">o</span><p id="par0305" class="elsevierStylePara elsevierViewall">There must be a transfer ventilator for every 10 patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">o</span><p id="par0310" class="elsevierStylePara elsevierViewall">All these aspects must be taken into account when generating extraordinary ICU spaces in other areas of the hospital&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">o</span><p id="par0315" class="elsevierStylePara elsevierViewall">It is advisable to maintain grouping and isolation by cohorts&#46;</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">o</span><p id="par0320" class="elsevierStylePara elsevierViewall">Grouping by cohorts should prevail over the concept of rooms with closed doors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">o</span><p id="par0325" class="elsevierStylePara elsevierViewall">If an ICU has open and closed boxes&#44; it is advisable to initially use the closed boxes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">o</span><p id="par0330" class="elsevierStylePara elsevierViewall">If necessary&#44; the physical space of the ICU should be expanded&#46;</p></li></ul></p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Human resources</span><p id="par0335" class="elsevierStylePara elsevierViewall">Each center requires a care modification plan contemplating the distribution of workloads&#44; care responsibilities and working hours or shifts&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">The following is recommended in reference to intensivists<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#58;<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">o</span><p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Normal work shift</span>&#58;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">-</span><p id="par0350" class="elsevierStylePara elsevierViewall">An intensivist for every three patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">-</span><p id="par0355" class="elsevierStylePara elsevierViewall">In the event of saturation&#44; other non-intensivist physicians &#40;including residents in training&#41; may be incorporated&#44; coordinated by an intensivist&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">o</span><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Duty shift</span>&#58;<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">-</span><p id="par0365" class="elsevierStylePara elsevierViewall">Two intensivists or an intensivist plus a fourth- or fifth-year resident for every 12 beds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">-</span><p id="par0370" class="elsevierStylePara elsevierViewall">In the event of saturation&#44; other non-intensivist physicians &#40;including residents in training&#41; may be incorporated&#44; coordinated by an intensivist&#46;</p></li></ul></p></li></ul></p><p id="par0375" class="elsevierStylePara elsevierViewall">The following is recommended in reference to nursing staff<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#58;<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">o</span><p id="par0380" class="elsevierStylePara elsevierViewall">A nursing professional per shift for every two critical patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">o</span><p id="par0385" class="elsevierStylePara elsevierViewall">Reinforcement with one nurse for every 4&#8211;6 beds as support in moments of maximum workload &#40;prone positioning&#44; intubation&#44; transfers&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">o</span><p id="par0390" class="elsevierStylePara elsevierViewall">A nursing assistant &#40;NA&#41; for every 4 beds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">o</span><p id="par0395" class="elsevierStylePara elsevierViewall">Reinforcement per shift for every 8&#8211;12 beds for organization and cleaning of material&#44; support and replacement&#46;</p></li></ul></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Staff training<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></span><p id="par0400" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">o</span><p id="par0405" class="elsevierStylePara elsevierViewall">The SEMICYUC will generate training material&#58; charts&#44; diagrams&#44; posters&#44; etc&#46;</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">o</span><p id="par0410" class="elsevierStylePara elsevierViewall">Each hospital should organize training sessions with at least the following contents&#58;<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">-</span><p id="par0415" class="elsevierStylePara elsevierViewall">Epidemiology of COVID-19&#46;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">-</span><p id="par0420" class="elsevierStylePara elsevierViewall">Impact upon activity&#46;</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">-</span><p id="par0425" class="elsevierStylePara elsevierViewall">Transmission&#46;</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">-</span><p id="par0430" class="elsevierStylePara elsevierViewall">Diagnosis of COVID-19&#46;</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">-</span><p id="par0435" class="elsevierStylePara elsevierViewall">Personal protection measures&#58; personal protective equipment &#40;PPE&#41;&#44; procedures and isolation&#46;</p></li></ul></p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Internal communication&#46; Transmission of information</span><p id="par0440" class="elsevierStylePara elsevierViewall">We recommend the following<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>&#58;<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">o</span><p id="par0445" class="elsevierStylePara elsevierViewall">Definition of an information transmission protocol&#46;</p></li><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">o</span><p id="par0450" class="elsevierStylePara elsevierViewall">Avoid close contact during the transmission of information&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">o</span><p id="par0455" class="elsevierStylePara elsevierViewall">Take special care in transmitting the therapeutic plan and the anticipation of changes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">o</span><p id="par0460" class="elsevierStylePara elsevierViewall">Use structured transmission&#44; for example based on SBAR &#40;Situation-Background-Assessment-Recommendation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0345"><span class="elsevierStyleLabel">o</span><p id="par0465" class="elsevierStylePara elsevierViewall">Adequate completion the patient clinical history&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Communication with and information for patients and relatives</span><p id="par0470" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0350"><span class="elsevierStyleLabel">o</span><p id="par0475" class="elsevierStylePara elsevierViewall">In those ICUs with cases of COVID-19&#44; it is advisable for the families of all the admitted patients to be informed of the fact on a daily basis&#44; as well as of the moment in which there no longer are any such cases&#8212;without providing any other type of information that may affect the intimacy of such patients and their families&#46;</p></li><li class="elsevierStyleListItem" id="lsti0355"><span class="elsevierStyleLabel">o</span><p id="par0480" class="elsevierStylePara elsevierViewall">In those ICUs with cases of COVID-19&#44; it is advisable for the families of the admitted patients to receive the usual daily information from the team outside the Unit&#46;</p></li><li class="elsevierStyleListItem" id="lsti0360"><span class="elsevierStyleLabel">o</span><p id="par0485" class="elsevierStylePara elsevierViewall">The patients with COVID-19 are to be isolated&#44; with absolute restriction of accompaniment&#47;visits&#46; Only in situations analyzed on an individualized basis by the medical team&#44; due to strict necessity &#40;e&#46;g&#46;&#44; in imminent death situations&#41; or based on other clinical&#44; ethical and&#47;or humane considerations&#44; will limited&#44; controlled&#44; brief and supervised visits be allowed&#44; after instructing the relatives on how to wear and remove the PPE&#44; with due help and supervision&#46;</p></li><li class="elsevierStyleListItem" id="lsti0365"><span class="elsevierStyleLabel">o</span><p id="par0490" class="elsevierStylePara elsevierViewall">The families are to be advised to minimize patient accompaniment as far as possible&#44; regardless of whether the patient has COVID-19 or not&#46;</p></li><li class="elsevierStyleListItem" id="lsti0370"><span class="elsevierStyleLabel">o</span><p id="par0495" class="elsevierStylePara elsevierViewall">Visits to patients without COVID-19 in Units where COVID-19 cases are present are to be adapted to the architectural characteristics of the Unit&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Optimized use of resources</span><p id="par0500" class="elsevierStylePara elsevierViewall">Coronavirus is mainly transmitted by respiratory droplets measuring over 5&#8239;&#956;m in size and through direct contact with the secretions of infected individuals&#46; It may also be transmitted by the aerosols produced during therapeutic procedures&#46; We therefore recommend the following<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;17</span></a>&#58;<ul class="elsevierStyleList" id="lis0100"><li class="elsevierStyleListItem" id="lsti0375"><span class="elsevierStyleLabel">o</span><p id="par0505" class="elsevierStylePara elsevierViewall">The precautions for the treatment of all patients under study as probable cases or with confirmed infection must include the standard measures referred to contact and the transmission of droplets&#46;</p></li><li class="elsevierStyleListItem" id="lsti0380"><span class="elsevierStyleLabel">o</span><p id="par0510" class="elsevierStylePara elsevierViewall">Strict hand hygiene is mandatory&#46;</p></li><li class="elsevierStyleListItem" id="lsti0385"><span class="elsevierStyleLabel">o</span><p id="par0515" class="elsevierStylePara elsevierViewall">All the professionals must be trained in the use of PPE&#46;</p></li><li class="elsevierStyleListItem" id="lsti0390"><span class="elsevierStyleLabel">o</span><p id="par0520" class="elsevierStylePara elsevierViewall">Ideally&#44; the patients should remain isolated in an individual room&#44; and if possible under negative pressure&#46;</p></li><li class="elsevierStyleListItem" id="lsti0395"><span class="elsevierStyleLabel">o</span><p id="par0525" class="elsevierStylePara elsevierViewall">Priority should be placed on patient grouping &#40;cohorting&#41; in a specific area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0400"><span class="elsevierStyleLabel">o</span><p id="par0530" class="elsevierStylePara elsevierViewall">The generated waste is regarded as class III waste&#46;</p></li><li class="elsevierStyleListItem" id="lsti0405"><span class="elsevierStyleLabel">o</span><p id="par0535" class="elsevierStylePara elsevierViewall">The PPE is to be removed within the box&#44; except for the respiratory and eye protection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0410"><span class="elsevierStyleLabel">o</span><p id="par0540" class="elsevierStylePara elsevierViewall">The clothing and utensils require no special treatment&#46;</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Personal protective equipment</span><p id="par0545" class="elsevierStylePara elsevierViewall">Such equipment must include<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#58;<ul class="elsevierStyleList" id="lis0105"><li class="elsevierStyleListItem" id="lsti0415"><span class="elsevierStyleLabel">o</span><p id="par0550" class="elsevierStylePara elsevierViewall">Protective clothing and gloves&#46;</p></li><li class="elsevierStyleListItem" id="lsti0420"><span class="elsevierStyleLabel">o</span><p id="par0555" class="elsevierStylePara elsevierViewall">Respiratory protection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0425"><span class="elsevierStyleLabel">o</span><p id="par0560" class="elsevierStylePara elsevierViewall">Protection of the eyes and face&#46;</p></li></ul></p><p id="par0565" class="elsevierStylePara elsevierViewall">The following recommendations are made with regard to respiratory protection<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;16</span></a>&#58;<ul class="elsevierStyleList" id="lis0110"><li class="elsevierStyleListItem" id="lsti0430"><span class="elsevierStyleLabel">o</span><p id="par0570" class="elsevierStylePara elsevierViewall">Patients with confirmed infection and cases under investigation should wear surgical masks&#44; if possible&#46;</p></li><li class="elsevierStyleListItem" id="lsti0435"><span class="elsevierStyleLabel">o</span><p id="par0575" class="elsevierStylePara elsevierViewall">Use two high efficacy antimicrobial filters &#40;inspiratory and expiratory arms&#41; in the case of invasive mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0440"><span class="elsevierStyleLabel">o</span><p id="par0580" class="elsevierStylePara elsevierViewall">Use closed aspiration systems&#46;</p></li><li class="elsevierStyleListItem" id="lsti0445"><span class="elsevierStyleLabel">o</span><p id="par0585" class="elsevierStylePara elsevierViewall">In the case of noninvasive ventilation&#44; it is advisable to use antiviral filters and preferably double tubing equipment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0450"><span class="elsevierStyleLabel">o</span><p id="par0590" class="elsevierStylePara elsevierViewall">Avoid manual ventilation with bag mask&#46; If done&#44; use a high efficacy antimicrobial filter&#46;</p></li><li class="elsevierStyleListItem" id="lsti0455"><span class="elsevierStyleLabel">o</span><p id="par0595" class="elsevierStylePara elsevierViewall">Avoid active humidification&#44; aerosol therapy and circuit disconnections&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0460"><span class="elsevierStyleLabel">o</span><p id="par0600" class="elsevierStylePara elsevierViewall">When entering the room&#44; or within a perimeter of 2&#8239;m from the patient&#44; if aerosol-generating procedures are not going to be carried out&#44; it is advisable to wear<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#58;<ul class="elsevierStyleList" id="lis0115"><li class="elsevierStyleListItem" id="lsti0465"><span class="elsevierStyleLabel">-</span><p id="par0605" class="elsevierStylePara elsevierViewall">A gown &#40;disposable paper gowns are allowed&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0470"><span class="elsevierStyleLabel">-</span><p id="par0610" class="elsevierStylePara elsevierViewall">Mask &#40;surgical mask or FFP2 if available&#44; and always ensuring the existence of a sufficient stock&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0475"><span class="elsevierStyleLabel">-</span><p id="par0615" class="elsevierStylePara elsevierViewall">Gloves&#46;</p></li><li class="elsevierStyleListItem" id="lsti0480"><span class="elsevierStyleLabel">-</span><p id="par0620" class="elsevierStylePara elsevierViewall">Anti-splash safety goggles&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0485"><span class="elsevierStyleLabel">o</span><p id="par0625" class="elsevierStylePara elsevierViewall">If an aerosol-generating procedure is to be carried out&#44; it is advisable to wear<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;18</span></a>&#58;<ul class="elsevierStyleList" id="lis0120"><li class="elsevierStyleListItem" id="lsti0490"><span class="elsevierStyleLabel">-</span><p id="par0630" class="elsevierStylePara elsevierViewall">An FFP2mask or preferably FFP3 mask&#44; if available&#46;</p></li><li class="elsevierStyleListItem" id="lsti0495"><span class="elsevierStyleLabel">-</span><p id="par0635" class="elsevierStylePara elsevierViewall">Adjusted integral eye protection or complete face mask&#46;</p></li><li class="elsevierStyleListItem" id="lsti0500"><span class="elsevierStyleLabel">-</span><p id="par0640" class="elsevierStylePara elsevierViewall">Gloves&#46;</p></li><li class="elsevierStyleListItem" id="lsti0505"><span class="elsevierStyleLabel">-</span><p id="par0645" class="elsevierStylePara elsevierViewall">Impermeable long-sleeved gown&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0510"><span class="elsevierStyleLabel">o</span><p id="par0650" class="elsevierStylePara elsevierViewall">The current recommendation is to use the mask only once&#46; Although clear evidence is lacking&#44; in the event of a scarcity of masks&#44; they can be reused by the same professional for a maximum of 8&#8239;h of continuous or intermittent activity&#46; Extended use of the mask is allowed provided it is not stained or humid&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li></ul></p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Optimization of PPE use</span><p id="par0655" class="elsevierStylePara elsevierViewall">Rational PPE use is required&#44; with minimization of the exposure times&#46; The following recommendations are made in this regard&#58;<ul class="elsevierStyleList" id="lis0125"><li class="elsevierStyleListItem" id="lsti0515"><span class="elsevierStyleLabel">o</span><p id="par0660" class="elsevierStylePara elsevierViewall">Promote recording&#44; control and monitoring measures that do not require entering the room of the patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0520"><span class="elsevierStyleLabel">o</span><p id="par0665" class="elsevierStylePara elsevierViewall">Plan the tasks and remain in the room as briefly as possible&#46;</p></li><li class="elsevierStyleListItem" id="lsti0525"><span class="elsevierStyleLabel">o</span><p id="par0670" class="elsevierStylePara elsevierViewall">Group those tasks requiring entry to the box&#46;</p></li><li class="elsevierStyleListItem" id="lsti0530"><span class="elsevierStyleLabel">o</span><p id="par0675" class="elsevierStylePara elsevierViewall">Adjust the perfusions to make the changes during scheduled entry to the box&#46;</p></li><li class="elsevierStyleListItem" id="lsti0535"><span class="elsevierStyleLabel">o</span><p id="par0680" class="elsevierStylePara elsevierViewall">Perform care&#44; explorations&#44; etc&#46;&#44; with the fewest persons possible&#46;</p></li><li class="elsevierStyleListItem" id="lsti0540"><span class="elsevierStyleLabel">o</span><p id="par0685" class="elsevierStylePara elsevierViewall">Avoid per protocol aspiration&#46;</p></li><li class="elsevierStyleListItem" id="lsti0545"><span class="elsevierStyleLabel">o</span><p id="par0690" class="elsevierStylePara elsevierViewall">Unify sampling to avoid unnecessary entries&#46;<ul class="elsevierStyleList" id="lis0130"><li class="elsevierStyleListItem" id="lsti0550"><span class="elsevierStyleLabel">-</span><p id="par0695" class="elsevierStylePara elsevierViewall">Prepare the sample for transport in the box&#46;</p></li><li class="elsevierStyleListItem" id="lsti0555"><span class="elsevierStyleLabel">-</span><p id="par0700" class="elsevierStylePara elsevierViewall">Clean the outer part of the tube with surface disinfectant or a small towel impregnated with disinfectant&#46;</p></li><li class="elsevierStyleListItem" id="lsti0560"><span class="elsevierStyleLabel">-</span><p id="par0705" class="elsevierStylePara elsevierViewall">Sample transport is to be done personally&#44; avoiding transport systems such as pneumatic tubes&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0565"><span class="elsevierStyleLabel">o</span><p id="par0710" class="elsevierStylePara elsevierViewall">The professionals in charge of the patient must supervise any intervention upon the patient by staff not belonging to the Unit&#46;</p></li></ul></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Indications of admission to the ICU in patients with SARS-CoV-2 pneumonia</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">General criteria for admission to the ICU</span><p id="par0715" class="elsevierStylePara elsevierViewall">We recommend the use of objective ICU admission criteria based on the recommendations of the American Thoracic Society &#40;ATS&#41;&#44; the Infectious Diseases Society of America &#40;IDSA&#41;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> and the recent evidence of the analysis of the SARS-CoV-2 &#40;COVID-19&#41; epidemic in China<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Admission to the ICU is to be considered in the presence of one major criterion or three or more minor criteria&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Optimization in case of saturation</span><p id="par0720" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0135"><li class="elsevierStyleListItem" id="lsti0570"><span class="elsevierStyleLabel">o</span><p id="par0725" class="elsevierStylePara elsevierViewall">In cases of saturation or overwhelming workload&#44; priority must center on those patients most likely to recover&#46;</p></li><li class="elsevierStyleListItem" id="lsti0575"><span class="elsevierStyleLabel">o</span><p id="par0730" class="elsevierStylePara elsevierViewall">The ICU triage or screening protocols referred to pandemics should only be activated if the ICU resources in a large geographic area have become or are going to become overwhelmed despite all reasonable efforts to expand resources or obtain additional resources&#46;</p></li><li class="elsevierStyleListItem" id="lsti0580"><span class="elsevierStyleLabel">o</span><p id="par0735" class="elsevierStylePara elsevierViewall">It is essential to have guidelines on the adequacy of therapeutic effort&#46;</p></li></ul></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Inclusion&#47;exclusion criteria<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;25</span></a></span><p id="par0740" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0140"><li class="elsevierStyleListItem" id="lsti0585"><span class="elsevierStyleLabel">o</span><p id="par0745" class="elsevierStylePara elsevierViewall">A screening instrument capable of objectively classifying the patients is advised&#46;</p></li><li class="elsevierStyleListItem" id="lsti0590"><span class="elsevierStyleLabel">o</span><p id="par0750" class="elsevierStylePara elsevierViewall">While not validated&#44; the only measure proposed to date is based on the use of the SOFA score&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></li><li class="elsevierStyleListItem" id="lsti0595"><span class="elsevierStyleLabel">o</span><p id="par0755" class="elsevierStylePara elsevierViewall">Following the first assessment&#44; the patients are to be re-evaluated on days 2 and 5&#44; which is when reclassification may be made&#46;</p></li><li class="elsevierStyleListItem" id="lsti0600"><span class="elsevierStyleLabel">o</span><p id="par0760" class="elsevierStylePara elsevierViewall">The following are exclusion criteria for admission&#58;<ul class="elsevierStyleList" id="lis0145"><li class="elsevierStyleListItem" id="lsti0605"><span class="elsevierStyleLabel">-</span><p id="par0765" class="elsevierStylePara elsevierViewall">Poor prognosis despite admission to the ICU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0610"><span class="elsevierStyleLabel">-</span><p id="par0770" class="elsevierStylePara elsevierViewall">Need for resources that cannot be provided&#46;</p></li><li class="elsevierStyleListItem" id="lsti0615"><span class="elsevierStyleLabel">-</span><p id="par0775" class="elsevierStylePara elsevierViewall">Failure to meet severity criteria&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0620"><span class="elsevierStyleLabel">o</span><p id="par0780" class="elsevierStylePara elsevierViewall">Application can be made of the specific recommendations on admission exclusion referred to mass casualty events&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></li></ul></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Expansion plan</span><p id="par0785" class="elsevierStylePara elsevierViewall">The expansion plan includes the transformation and preparation of additional spaces for the care of critical patients in situations of ICU bed collapse&#44; as well as an increase in the number of staff members with expertise in the care of critical patients&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Expansion of the departments of intensive care medicine</span><p id="par0790" class="elsevierStylePara elsevierViewall">The possible locations for the stay of critical patients must be equipped with<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;26&#44;27</span></a>&#58;<ul class="elsevierStyleList" id="lis0150"><li class="elsevierStyleListItem" id="lsti0625"><span class="elsevierStyleLabel">o</span><p id="par0795" class="elsevierStylePara elsevierViewall">Medicinal gases&#46;</p></li><li class="elsevierStyleListItem" id="lsti0630"><span class="elsevierStyleLabel">o</span><p id="par0800" class="elsevierStylePara elsevierViewall">Respirators for invasive and noninvasive mechanical ventilation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0635"><span class="elsevierStyleLabel">o</span><p id="par0805" class="elsevierStylePara elsevierViewall">Possibility of high-flow oxygen therapy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0640"><span class="elsevierStyleLabel">o</span><p id="par0810" class="elsevierStylePara elsevierViewall">Possibility of advanced monitoring&#46;</p></li><li class="elsevierStyleListItem" id="lsti0645"><span class="elsevierStyleLabel">o</span><p id="par0815" class="elsevierStylePara elsevierViewall">Possibility of continuous extrarenal replacement therapy techniques&#46;</p></li><li class="elsevierStyleListItem" id="lsti0650"><span class="elsevierStyleLabel">o</span><p id="par0820" class="elsevierStylePara elsevierViewall">Points for hand hygiene&#46;</p></li><li class="elsevierStyleListItem" id="lsti0655"><span class="elsevierStyleLabel">o</span><p id="par0825" class="elsevierStylePara elsevierViewall">Availability of central monitoring &#40;telemetry&#41; would be desirable&#46;</p></li></ul></p><p id="par0830" class="elsevierStylePara elsevierViewall">On an orientative basis&#44; the spaces that can be used to expand the number of ICU beds are<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>&#58;<ul class="elsevierStyleList" id="lis0155"><li class="elsevierStyleListItem" id="lsti0660"><span class="elsevierStyleLabel">o</span><p id="par0835" class="elsevierStylePara elsevierViewall">Intermediate care units attended by intensivists&#58; the nurse-to-patient ratios must be adjusted to those of a conventional ICU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0665"><span class="elsevierStyleLabel">o</span><p id="par0840" class="elsevierStylePara elsevierViewall">Resuscitation units and post-anesthesia recovery units&#46; Scheduled surgery must be suspended&#46; The patients are to be attended by intensivists&#46;</p></li><li class="elsevierStyleListItem" id="lsti0670"><span class="elsevierStyleLabel">o</span><p id="par0845" class="elsevierStylePara elsevierViewall">Critical care or intermediate care areas of the emergency rooms&#46;</p></li><li class="elsevierStyleListItem" id="lsti0675"><span class="elsevierStyleLabel">o</span><p id="par0850" class="elsevierStylePara elsevierViewall">Habilitation of space close to the ICU&#44; with new provision of equipment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0680"><span class="elsevierStyleLabel">o</span><p id="par0855" class="elsevierStylePara elsevierViewall">Transformation of conventional hospitalization areas&#44; day hospitals or ambulatory major surgery areas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0685"><span class="elsevierStyleLabel">o</span><p id="par0860" class="elsevierStylePara elsevierViewall">In the event of oversaturation&#44; transfer to another center with available space must be considered&#46;</p></li></ul></p><p id="par0865" class="elsevierStylePara elsevierViewall">If 100&#37; saturation of the Departments of Intensive Care Medicine is anticipated&#44; we recommend centralization of the resources&#44; with&#58;<ul class="elsevierStyleList" id="lis0160"><li class="elsevierStyleListItem" id="lsti0690"><span class="elsevierStyleLabel">o</span><p id="par0870" class="elsevierStylePara elsevierViewall">Development of an inter-hospital transfer protocol&#46;</p></li><li class="elsevierStyleListItem" id="lsti0695"><span class="elsevierStyleLabel">o</span><p id="par0875" class="elsevierStylePara elsevierViewall">Creation in each Autonomous Community of a critical patients coordinator for the integral management of all critical care beds in each Community&#46;</p></li></ul></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Staff expansion</span><p id="par0880" class="elsevierStylePara elsevierViewall">We recommend the following<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a>&#58;<ul class="elsevierStyleList" id="lis0165"><li class="elsevierStyleListItem" id="lsti0700"><span class="elsevierStyleLabel">o</span><p id="par0885" class="elsevierStylePara elsevierViewall">Establish a census of all specialists in Intensive Care Medicine&#44; including also&#58;<ul class="elsevierStyleList" id="lis0170"><li class="elsevierStyleListItem" id="lsti0705"><span class="elsevierStyleLabel">-</span><p id="par0890" class="elsevierStylePara elsevierViewall">Physicians with on-duty contracts&#46;</p></li><li class="elsevierStyleListItem" id="lsti0710"><span class="elsevierStyleLabel">-</span><p id="par0895" class="elsevierStylePara elsevierViewall">Intensivists dedicated to other tasks within the hospital&#46;</p></li><li class="elsevierStyleListItem" id="lsti0715"><span class="elsevierStyleLabel">-</span><p id="par0900" class="elsevierStylePara elsevierViewall">Unemployed physicians&#46;</p></li><li class="elsevierStyleListItem" id="lsti0720"><span class="elsevierStyleLabel">-</span><p id="par0905" class="elsevierStylePara elsevierViewall">Newly retired physicians&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0725"><span class="elsevierStyleLabel">o</span><p id="par0910" class="elsevierStylePara elsevierViewall">Establish a census of other staff physicians or residents that may be able to care for less seriously ill patients&#44; coordinated by the Department of Intensive Care Medicine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0730"><span class="elsevierStyleLabel">o</span><p id="par0915" class="elsevierStylePara elsevierViewall">Prolong substitution contracts&#46;</p></li><li class="elsevierStyleListItem" id="lsti0735"><span class="elsevierStyleLabel">o</span><p id="par0920" class="elsevierStylePara elsevierViewall">Establish a plan for physician staff provision and distribution of workloads in all the hospitals&#46;</p></li><li class="elsevierStyleListItem" id="lsti0740"><span class="elsevierStyleLabel">o</span><p id="par0925" class="elsevierStylePara elsevierViewall">Establish a census of the nursing staff with knowledge and experience in the care of critical patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0745"><span class="elsevierStyleLabel">o</span><p id="par0930" class="elsevierStylePara elsevierViewall">Develop a plan for the reallocation of experienced nursing staff towards critical care areas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0750"><span class="elsevierStyleLabel">o</span><p id="par0935" class="elsevierStylePara elsevierViewall">Take into account the previsions referred to peak care burden&#46;</p></li><li class="elsevierStyleListItem" id="lsti0755"><span class="elsevierStyleLabel">o</span><p id="par0940" class="elsevierStylePara elsevierViewall">If medical or nursing staff members that do not carry out their regular work in critical care become necessary&#44; they should receive prior training&#46;</p></li><li class="elsevierStyleListItem" id="lsti0760"><span class="elsevierStyleLabel">o</span><p id="par0945" class="elsevierStylePara elsevierViewall">Such training should focus on two main areas&#58; intensive care medicine or nursing and control of infections&#46;</p></li></ul></p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Transfers</span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Inter-hospital transfer</span><p id="par0950" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0175"><li class="elsevierStyleListItem" id="lsti0765"><span class="elsevierStyleLabel">o</span><p id="par0955" class="elsevierStylePara elsevierViewall">Staff required&#58; attending physician&#44; attending nurse and emergency care technician&#46;</p></li><li class="elsevierStyleListItem" id="lsti0770"><span class="elsevierStyleLabel">o</span><p id="par0960" class="elsevierStylePara elsevierViewall">The adequate PPE for the attending staff is that recommended for situations of aerosol generation risk&#46;</p></li><li class="elsevierStyleListItem" id="lsti0775"><span class="elsevierStyleLabel">o</span><p id="par0965" class="elsevierStylePara elsevierViewall">To be taken into account during transfer&#58;<ul class="elsevierStyleList" id="lis0180"><li class="elsevierStyleListItem" id="lsti0780"><span class="elsevierStyleLabel">-</span><p id="par0970" class="elsevierStylePara elsevierViewall">Isolation of the staff in charge of driving the transfer vehicle&#46;</p></li><li class="elsevierStyleListItem" id="lsti0785"><span class="elsevierStyleLabel">-</span><p id="par0975" class="elsevierStylePara elsevierViewall">The relatives cannot travel with the transfer vehicle&#46;</p></li><li class="elsevierStyleListItem" id="lsti0790"><span class="elsevierStyleLabel">-</span><p id="par0980" class="elsevierStylePara elsevierViewall">Limitation of the number of caregivers in the transfer vehicle&#46;</p></li></ul></p></li></ul></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Intra-hospital transfer</span><p id="par0985" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0185"><li class="elsevierStyleListItem" id="lsti0795"><span class="elsevierStyleLabel">o</span><p id="par0990" class="elsevierStylePara elsevierViewall">A transfer circuit protocol is to be established&#58; itinerary&#44; elevator&#44; number of intervening persons&#44; PPE&#46;</p></li><li class="elsevierStyleListItem" id="lsti0800"><span class="elsevierStyleLabel">o</span><p id="par0995" class="elsevierStylePara elsevierViewall">Steps for transfer&#58;<ul class="elsevierStyleList" id="lis0190"><li class="elsevierStyleListItem" id="lsti0805"><span class="elsevierStyleLabel">1</span><p id="par1000" class="elsevierStylePara elsevierViewall">Inform the receiving Department&#44; cleanliness and safety&#46;</p></li><li class="elsevierStyleListItem" id="lsti0810"><span class="elsevierStyleLabel">2</span><p id="par1005" class="elsevierStylePara elsevierViewall">Prepare the material&#46;</p></li><li class="elsevierStyleListItem" id="lsti0815"><span class="elsevierStyleLabel">3</span><p id="par1010" class="elsevierStylePara elsevierViewall">Use PPE&#46;</p></li><li class="elsevierStyleListItem" id="lsti0820"><span class="elsevierStyleLabel">4</span><p id="par1015" class="elsevierStylePara elsevierViewall">Notify the receiving Department of the start of transfer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0825"><span class="elsevierStyleLabel">5</span><p id="par1020" class="elsevierStylePara elsevierViewall">Block the elevator for transfer and disinfection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0830"><span class="elsevierStyleLabel">6</span><p id="par1025" class="elsevierStylePara elsevierViewall">Security staff with surgical masks are to precede the team to clear the zone&#46;</p></li><li class="elsevierStyleListItem" id="lsti0835"><span class="elsevierStyleLabel">7</span><p id="par1030" class="elsevierStylePara elsevierViewall">Disinfection of the zones of transfer&#46;</p></li><li class="elsevierStyleListItem" id="lsti0840"><span class="elsevierStyleLabel">8</span><p id="par1035" class="elsevierStylePara elsevierViewall">Return&#46;</p></li></ul></p></li></ul></p></span></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflicts of interest</span><p id="par1040" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "titulo" => "Previsions for the COVID-19 pandemic"
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              "titulo" => "Phase 3&#46; Collapse of the ICU and of the hospital"
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          "titulo" => "Human and technical resource requirements"
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              "titulo" => "Internal communication&#46; Transmission of information"
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              "titulo" => "Indications of admission to the ICU in patients with SARS-CoV-2 pneumonia"
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                  "titulo" => "General criteria for admission to the ICU"
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                  "titulo" => "Inclusion&#47;exclusion criteria"
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                3 => array:2 [
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                  "titulo" => "Expansion plan"
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                  "identificador" => "sec0115"
                  "titulo" => "Expansion of the departments of intensive care medicine"
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                  "titulo" => "Staff expansion"
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              "titulo" => "Transfers"
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            2 => "SARS-CoV-2"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In January 2020&#44; the Chinese authorities identified a new virus of the <span class="elsevierStyleItalic">Coronaviridae</span> family as the cause of several cases of pneumonia of unknown aetiology&#46; The outbreak was initially confined to Wuhan City&#44; but then spread outside Chinese borders&#46; On 31 January 2020&#44; the first case was declared in Spain&#46; On 11 March 2020&#44; The World Health Organization &#40;WHO&#41; declared the coronavirus outbreak a pandemic&#46; On 16 March 2020&#44; there were 139 countries affected&#46; In this situation&#44; the Scientific Societies SEMICYUC and SEEIUC&#44; have decided to draw up this Contingency Plan to guide the response of the Intensive Care Services&#46; The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources&#46; This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En enero de 2020 China identific&#243; un nuevo virus de la familia de los <span class="elsevierStyleItalic">Coronaviridae</span> como causante de varios casos de neumon&#237;a de origen desconocido&#46; Inicialmente confinado a la ciudad de Wuhan&#44; se extendi&#243; posteriormente fuera de las fronteras chinas&#46; En Espa&#241;a&#44; el primer caso se declar&#243; el 31 de enero de 2020&#46; El 11 de marzo&#44; la Organizaci&#243;n Mundial de la Salud declar&#243; el brote de coronavirus como pandemia&#46; El 16 de marzo hab&#237;a 139 pa&#237;ses afectados&#46; Ante esta situaci&#243;n&#44; las Sociedades Cient&#237;ficas SEMICYUC y SEEIUC han decidido la elaboraci&#243;n de este plan de contingencia para dar respuesta a las necesidades que conllevar&#225; esta nueva enfermedad&#46; Se pretende estimar la magnitud del problema e identificar las necesidades asistenciales&#44; de recursos humanos y materiales&#44; de manera que los servicios de medicina intensiva del pa&#237;s tengan una herramienta que les permita una planificaci&#243;n &#243;ptima y realista con que responder a la pandemia&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rascado Sedes P&#44; Ballesteros Sanz MA&#44; Bod&#237; Saera MA&#44; Carrasco Rodr&#237;guez-Rey LF&#44; Castellanos Ortega &#193;&#44; Catal&#225;n Gonz&#225;lez M&#44; et al&#46; Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19&#46; Med Intensiva&#46; 2020&#59;44&#58;363&#8211;370&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The components of the SEMICYUC Board of Directors appear in <a class="elsevierStyleCrossRef" href="#sec0145">Appendix A</a>&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The components of the SEEIUC Board of Directors appear in <a class="elsevierStyleCrossRef" href="#sec0150">Appendix B</a>&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is published simultaneously in <span class="elsevierStyleItalic">Medicina Intensiva</span> &#40;https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;medin&#46;2020&#46;03&#46;006&#41; and in <span class="elsevierStyleItalic">Enfermer&#237;a Intensiva</span> &#40;https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;enfi&#46;2020&#46;03&#46;001&#41;&#44; with the consent of the authors and editors&#46;</p>"
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            "apendice" => "<p id="par1045" class="elsevierStylePara elsevierViewall">Chairman&#58; Ricard Ferrer Roca&#46; Vice-chairman&#58; Alvaro Castellanos Ortega&#46; Secretary&#58; Josep Trenado Alvarez&#46; Vice-secretary&#58; Virginia Fraile Guti&#233;rrez&#46; Treasurer&#58; Alberto Hern&#225;ndez Tejedor&#46; Chairman of the Scientific Committee&#58; Manuel Herrera Guti&#233;rrez&#46; Vice-chairwoman of the Scientific Committee&#58; Paula Ram&#237;rez Galleymore&#46; Representative of the working groups&#58; M&#46; Angeles Ballesteros Sanz&#46; Representative of the Autonomous Societies&#58; Pedro Rascado Sedes&#46; Representative of the physicians in training&#58; Leire L&#243;pez del Oliva Calvo&#46; Previous Chairwoman&#58; Maria Cruz Mart&#237;n Delgado&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Steering Committee of the SEMICYUC"
            "identificador" => "sec0145"
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          1 => array:4 [
            "apendice" => "<p id="par1050" class="elsevierStylePara elsevierViewall">Chairwoman&#58; Marta Raurell Torreda&#46; Vice-chairwoman&#58; Miriam del Barrio Linares&#46; Secretary&#58; Marta Romero Garc&#237;a&#46; Treasurer&#58; Maria Teresa Ruiz Garc&#237;a&#46; Director of the journal&#58; Maria Pilar Delgado Hito&#46; Member of the working groups&#58; Juan Jos&#233; Rodr&#237;guez Mondejar&#46; Member of the Industry&#58; Carmen Moreno Arroyo&#46; Member of international relations&#58; Alicia San Jos&#233; Arribas&#46; Research member&#58; Maria Jesus Frade Mera&#46;</p>"
            "etiqueta" => "Appendix B"
            "titulo" => "Steering Committee of the SEEIUC"
            "identificador" => "sec0150"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2020.03.003

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2024 October	71	30	101
2024 September	84	46	130
2024 August	85	60	145
2024 July	92	39	131
2024 June	97	89	186
2024 May	76	49	125
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2024 March	96	31	127
2024 February	179	44	223
2024 January	75	44	119
2023 December	82	35	117
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2023 October	71	24	95
2023 September	109	54	163
2023 August	66	28	94
2023 July	84	40	124
2023 June	95	24	119
2023 May	107	56	163
2023 April	109	32	141
2023 March	167	41	208
2023 February	134	53	187
2023 January	94	36	130
2022 December	157	41	198
2022 November	172	48	220
2022 October	238	51	289
2022 September	214	70	284
2022 August	212	76	288
2022 July	249	49	298
2022 June	138	43	181
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2021 December	194	61	255
2021 November	210	46	256
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2021 August	312	61	373
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2021 June	255	63	318
2021 May	445	63	508
2021 April	692	58	750
2021 March	526	80	606
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2021 January	467	50	517
2020 December	424	67	491
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