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\begin{document}

\title{How to Rapidly Convert General Wards to ICUs during the COVID-19
Epidemic: Experience from Wuhan, Chin}



\author[1]{Mei He}%
\author[1]{Jie Xiong}%
\author[1]{Luhong Hu}%
\author[1]{Sufang Huang}%
\author[1]{Zhaoxia Li}%
\author[1]{Chunling Guo}%
\author[1]{Juan Deng}%
\affil[1]{Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\begin{abstract}
\textbf{Background} : Critically ill patients with coronavirus disease
2019(COVID-19)was surging and far outnumbered existing
beds.~\textbf{Aims} :\textbf{~} To describe how to rapidly convert
general wards to intensive care units for critically ill patients with
COVID-19.~\textbf{Materials \& Methods} :\textbf{~} Comprehensive
assessment and analysis of available resources and standard
requirements.~\textbf{Results} :~The ICUs were successfully assembled in
four days. The conversion included environment reconstruction,
configuration and management of equipment, information system
construction and human resource allocation. A total of 172 critically
ill patients had been admitted to the contemporary ICUs and none medical
staff was infected.~\textbf{Discussion} :\textbf{~} The epidemic
situation of COVID-19 poses a great challenge to various management
departments of the hospital, especially for critically ill patients with
high mortality rate. To save more critically ill patients, the
conversion of a general ward to a quarantine ICU ward must be completed
in a short time, and the optimal allocation of resources must be
appropriate to ensure that the medical team works effectively and is of
high quality. In face of the overloaded medical system, the ideal
non-negative pressure ward is hard to achieve. However, we have
demonstrated with evidence that our conversions are effective in both
providing care to the critical patients and protecting the safety of our
staff.~\textbf{Conclusion:~} The conversion is successful and the
running experience would be a reference for hospitals in other areas
nationally or globally.%
\end{abstract}%



\sloppy


\textbf{}Since January 2020, many cases of coronavirus disease 2019 have
been confirmed in China. Local officials had reported 47,647 new cases
of COVID-19 as of 24:00 on 21/2/2020, of which 10,892 were severe cases
(National Health Commission of the People's Republic of China, 2020).
The mortality rate of critically ill patients reached over 50\% (World
Health Organization, 2020a). To improve the treatment capacity for
critically ill patients and reduce mortality, one site at our hospital
was opened to admit patients with COVID-19. The original intensive care
unit at this site only had 20 beds. However, due to the fact that
critically ill patients far outnumbered existing beds, and the fact that
the use of the 10,000-level laminar flow system in the existing ICU was
not conducive to protecting medical staff, decision was made to convert
two general wards into two temporary ICUs, adding 72 beds for the
critical ill. To date, the two temporary ICUs run well. The experience
of assembling ICUs is described as follows.

\textbf{1. Ward Environment Reconstruction}

\textbf{1.1 Standard infectious ward layout}

Originally, there were two wards on each floor, located in the East area
and West area with a corridor between them. Thus, the doors in the
elevator area were blocked to connect the East and West areas as a
whole. Two additional doors were added to the original staff passage in
the West area and the original patient corridor in the East area to form
two buffer zones, forming a polluted area---buffer room---semi-polluted
area--- buffer room--- cleaning area layout (from west to east). The
West district served as a contaminated area ward for critically ill
patients with COVID and for removing the outermost protective equipment.
The section between West ward and East ward formed a semi-polluted area,
where medical care workstations, dispensing rooms, warehouses, and staff
toilets were set up. Staff also took off inner clothing here. The East
ward was set up as the staff-only clean areas, which are used by staff
to don protective equipment and store materials and as staff living
areas (Figure 1). The old staff passageway in the East district was
retained as the staff passageway, and the original dirt elevator,
located in the west ward, was converted into a patient passageway. The
original patient access door was blocked, and a continuously running air
curtain was installed near the ceiling above the door to promote the air
to flow from the clean area to the polluted area.

\textbf{1.2 Ward settings}

Hospital infection prevention and control standards for the intensive
care unit require that each ICU bed area should be no less than 15
m\textsuperscript{2} and that the bed spacing should be greater than one
meter (National Health Commission of the People's Republic of China,
2016). The original two general wards had 36 rooms, all of which were
triple rooms with below-standard bed spacing. Therefore, the triple
rooms were transformed into double rooms, which greatly increased the
bed spacing to more than one meter. For infectious wards, negative
airflow rooms are ideal. However, temporarily established ICUs were
exempted from meeting this criterion so long as the ward was
well-ventilated. Therefore, each ward was equipped with two exhaust fans
on the windows (approximately one meter above the ground) for continuous
ventilation, and the ventilation provided by each fan was ensured to be
at least 160 L/s (World Health Organization, 2020b). We opened the doors
and windows of the consultation room and temporary storage room directly
behind the nurse working station so that the air flowed from the clean
area to the polluted area and was finally discharged out of the window.
Except for the ceiling of the contaminated ward in the West district,
the ceilings of the other areas were all sealed with nonwoven fabrics to
avoid collusion with the air. To meet the needs of large numbers of
critical patients using oxygen at the same time, we increased the
pressure of the central oxygen supply equipment in the ward. .

\textbf{2. Configuration and Management of Equipment}

\textbf{2.1 Equipment selection and check}

Medical equipment manufacturers had donated many products with different
bands, including blood gas analyzers, continuous renal replacement
therapy (CRRT) instruments and extracorporeal membrane oxygenation
machines (ECMO). Personnel were required to participate in equipment
training, albeit efforts were made to coordinate medical teams from
different hospitals to use brands and models that they were familiar
with to minimize training time. At the same time, it was necessary to
implement a reserve of special consumables matching the instrument.

\textbf{2.2 Equipment management}

To ensure that rescue equipment was efficiently accessible to the entire
ward, each ICU ward was equipped with two emergency vehicles, with one
placed in the front ward and the other in the back ward. Two
defibrillators were stored in the nurse working station. Each bed was
equipped with an independent ECG monitor, a cart and a set of
disinfection supplies. To minimize cross-infection, we stopped the
original central suction equipment, and each bed was equipped with an
electric negative pressure suction device. Each ward was equipped with
20 high-flow airway humidification devices, 30 noninvasive ventilators
and 30 invasive ventilators with air compressors. In addition, it was
also equipped with two fiberoptic bronchoscopes, two
electrocardiographs, two vibration expectorators, two blood gas
analyzers and one portable bedside ultrasounds. Nonconventional ICU
equipment such as blood purification machines, ECMO machines and
packages were placed in storage areas in the semi-contaminated areas. In
emergency situations, this equipment was easily accessible and not
contaminated. We placed more than 40 medium rectangular storage boxes at
the nurses' workstation to store common disposable consumables by their
functionality, such as ''airway consumables'', and ''venous therapy
use''. Eye-catching labels were used for the convenience of medical
personnel wearing goggles and face shields.

\textbf{3. Information System Construction}

Each ward was equipped with a central real-time monitoring system that
displayed the vital signs of all patients on the monitoring screens in
the nurses' workstation and the medical station in the semi-contaminated
area. In each of the three zones, physician information stations and
nurse information stations were equipped with four computers. They were
used for document writing and prescribing medical orders. A certain
number of walkie-talkies were provided to each of the three areas for
calls and communication between staff. Each of the three districts was
equipped with a smart phone that could save and transmit documents,
recording and images. Additionally, we authorized all medical staff,
including out-of-province medical staff who came to support Wuhan, to
use open authority management, and reformat various document templates
and doctor order templates to ensure consistency.

\textbf{4. Human Resource Allocation}

\textbf{4.1 Establishment of a multidisciplinary team}

After the epidemic outbreak, medical staff from all over the country
came to provide aid. The two quarantine ICUs uniformly set up positions
and determined job responsibilities. Here we present the human resource
allocation strategy for one unit. Firstly, a multidisciplinary team was
formed, comprising of 25 physicians, 138 nurses, 24 nurse assistants,
six personals from infection control departments, two sonologists, one
dietician, one rehabilitation therapist, one psychological therapist and
one radiologist. Additionally, there were four experts took turns to
make the rounds of the wards.

\textbf{4.2 nurse staff allocation and support}

According to the requirements of Nosocomial Infection Prevention and
Control\textsuperscript{{[}3{]}}, the ICU should be equipped with a
sufficient number of professional medical staff. At that time, there
were 138 nursing staff, including 135 nurses and 3 head nurses, in
charge of 36 beds. The ratio of the number of nurses to the actual
number of beds was 3.8:1. We adopted a 4-hour shift model. That is, they
worked 4 hours a day for 6 consecutive days and took a day off after six
working days. The psychological counseling hotline in the mental
hospital was open 24 hours a day. Staff could call it for free whenever
they need to.

There are 18 primary nurses on duty during each shift. On average, one
nurse is in charge of two critically ill patients. Two additional nurses
are specialized in dealing with medical orders, informing corresponding
primary nurses, admitting patients, documenting critical values from the
clinical laboratory, replenishing supplies and rescue drugs, checking
accounts and discharging patients. One nurse is responsible for the
preparation of medicines for all patients in the ward and the
replenishment of commonly used medicine. The persons from the infection
control department hold the supervising position, whose job
responsibility includes checking and ensuring that all personnel wear
protective equipment appropriately when entering the ward, supplying
consumable items and clearing the semi-polluted area. One addtional
position was for staff catering, transportation and accommodation.

We set a lead nurse on each shift, who had the responsibilities of
managing, inspecting, supervising, guiding, and assigning patients to
each primary nurse. Each team consisted of nurses with ICU backgrounds
and non-ICU backgrounds. The combination of different working years was
another consideration.

\textbf{Running Effect}

From 4/2/2020 to3/4/2020, the wards have been running for 59 days. A
total of 172 critically ill patients with COVID-19 were admitted to the
temporary ICUs. Oxygen therapy is a key component of treatment for
patients with COVID-19 and mechanical ventilation was commonly used in
the critical ill. We had 126 patients who received invasive mechanical
ventilation and 68 patients who received noninvasive ventilation during
hospitalization. Fiberoptic bronchoscopy examination, as a high-risk
procedure, was also performed 43 times for diagnosis and treatment. To
protect the involved staff in this procedure, we developed a revised
standards for this procedure, including detailed preparation prior to
exam, precaution strategies and decontamination of bronchoscope and
environment. ECMO therapy is the last resort for maintaining critical
patients' respiratory and cardiac function. Six patients had undergone
this treatment in our unit. Additionally, 281 CRRTs and 15 tracheotomies
were successfully carried out at the patients' bedsides. In spite of the
heavy workload and high-risk working environment, none of the staff were
infected or had any mental health problems, fortunately.

\textbf{Acknowledgment:} The work is supported by the Nature Science
Foundation of Hubei Province {[}No.2019CFB645{]} for language editing.

\textbf{Conflicts of interest} : None.

\par\null

\textbf{References}

National Health Commission of the People's Republic of China, 2016.
Hospital Infection Prevention and Control Standards for the Intensive
Care Unit
{[}WS/T509{]}.\emph{http://www.nhc.gov.cn/wjw/s9496/201701/1f9de66563304061a4fcd7f54a9399fb.shtml}(accessed
20.03.26).

National Health Commission of the People's Republic of China, 2020.
Update on COVID-19
outbreak.\emph{http://www.nhc.gov.cn/xcs/yqtb/202002/543cc508978a48d2b9322bdc83daa6fd.shtml}(accessed
20.02.21).

World Health Organization. 2020a. Coronavirus disease 2019 (COVID-19)

Situation Report-41. https://www.who.int/docs/

default-source/coronaviruse/situation-reports/20200301-sitrep-41-covid-19.

pdf?sfvrsn=6768306d\_2(accessed 20.04.16).

World Health Organization, 2020b. Infection prevention and control
during health care when novel coronavirus (nCoV) infection is suspected,
interim
guidance.\emph{https://www.who.int/internal-publications-detail/surveillance-case-definitions-for-human-infection-withnovel-coronavirus-(ncov)}(accessed
20.03.20).

\textbf{Hosted file}

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