Table 4

Logistics involved in repurposing seven PICUs to care for critically ill adults—space, staff and equipment

HospitalsSt Mary’s HospitalRoyal Brompton HospitalRoyal London HospitalAlder Hey Children’s HospitalRoyal Manchester Children’s HospitalKing’s College HospitalRoyal Stoke University Hospital
Space management Entire PICU designated as COVID ‘red’ clinical zone.
Designated green zone for breaks and meetings to meet social distancing guidelines.
Internal paediatric emergencies needing critical care admitted to two negative-pressure cubicles.
Entire PICU designated as COVID ‘red’ clinical zone, and reorganisation of PICU/entrance to accommodate doffing.
Paediatric sleep unit converted as ‘green’ command-control centre and staff donning area.
Virtual handover and rounds allow maximising of the limited ‘green’ clinical space, so staff could join remotely.
Two cubicles kept for sole paediatric use.
Space around entrance and cubicles kept green. Designated areas for donning and AITU equipment created. New adult CD cupboard installed.
Two five-bedded bays increased to six beds each for adult patients tested positive for COVID. Towards end of the surge, newly expanded AITU was created to take patients tested positive for COVID, then PICU bays were used for green AITU patients.
Parent bedrooms converted to staff showering facitilites. Well-being space created. Designated green areas for staff breaks and handover.
Entire PICU+PHDU as COVID ‘red’ clinical zone.
Designated green zones for breaks and meetings.
Reconfigurated entrance and exit, and desginated donning-doffing areas.
PICU handovers in seminar room, AICU handovers in PPE in COVID pods.
Original PICU designated as COVID ‘red’ zone, primarily for adults, but one paediatric COVID case also cared for in this area.
Original PHDU refitted to accommodate 15 bed-spaces ring-fenced for PICU patients.
Burns unit closed to allow for separation of COVID zone staff for changing and refreshments, and donning/doffing.
Two separate handovers took place; a ‘COVID’ handover and a ‘non-COVID’ handover for the critically ill children now being cared for in the original PHDU.
Entire PICU as only ‘green’ zone that provided level 3 care for adult patients tested negative for COVID.
New King’s Critical Care Centre started functioning ahead of schedule provided space for 29 beds.
Entire PICU as COVID ‘red’ clinical zone.
Staffing
Medical: senior tier
Medical: middle and junior tiers
nursing
Led by PICU consultants on resident rota.
AICU consultants available on phone for advice.
PICU staff, mostly general paediatric trainees.
PICU nursing pool (some with previous AICU experience).
Led by PICU consultants on resident rota.
Day supporting rota of paediatric respiratory and cardiology consultants.
Senior AICU middle grade and consultants available for advice.
Middle-grade and junior-grade paediatric trainees from PICU, supplemented from cardiology and respiratory
PICU and AICU nursing pool, including some from recovery.
Paediatric ward nurses trained to supervise PPE donning and doffing stations.
Led by PICU consultants.
AICU consultants available for support, and anaesthetic consultants ad hoc.
PICU staff rota, included redeployed SHOs, neonatal fellows, surgical trainees.
Adult patients: AICU nurses supported by ODP and PICU nurses; while PICU nurses were redeployed to AICU.
Paediatric patients: PICU nurses.
Led by PICU consultants on resident rota.
Rota of seconded paediatric anaesthetic consultants.
AICU consultants available for phone advice.
Usual PICU rota plus three seconded paediatric SpRs and one anaesthetic fellow.
PICU nurses, operating theatre staff and previous staff with PICU experience.
PICU and AICU consultants jointly led till peak.
After peak, PICU consultants solely cared for paediatric patients, while AICU consultants and paediatric anaesthetists shared rota to care for adult patients.
Resident rota of PICU staff included ANPs, fellows, adult ICU and emergency medicine trainees, redeployed neonatal fellows and paediatric SHOs. Adult trainees worked mainly in the COVID zone allowing paediatric and neonatal trainees to manage the non-COVID critically ill children in the repurposed PHDU.
PICU nurses assisted by theatre-recovery staff.
Past PICU nurses redeployed from community and research roles.
Led by PICU consultants.
Supporting anaesthetists and AICU middle grade with twice daily adult consultant support rounds.
PICU staff and AICU trainees who previously rotated in PICU.
Dual-trained nursing pool, working alongside PICU nurses.
Paediatric clinical nurse specialists redeployed to PICU.
Led by PICU consultants on resident rota, supported by AICU consultants and general paediatricians.
Middle-grade paediatric trainees.
PICU nursing pool, supplemented from PHDU and general paediatric.
Education and training Webinars by AICU team.
Simulation training with anaesthetists and PICU multidisciplines.
AICU learning package: ‘ICU for non-adult intensivists’.
Daily support from regional adult critical care network.
Simulation training within the paediatric department led by the education teams.
Co-training with the adult team led by the anaesthetic department.
‘How to ICU’ portal access for protocol training.
Presurge training seminar.
Daily updates from AITU team via WhatsApp.
Access to AITU guidelines and protocols, daily check list.
Support from adult regional critical care network as needed.
AICU nurses supporting PICU nurses on the job.
AICU visit by Matron and PICU consultants.
Simulation and OSCE-style teaching by PICU nurses/ANPs.
Regional AICU guidelines, new regional and national COVID guidelines.
National and international webinars.
Daily support from adult regional critical care network.
Online resources.
Simulation sessions in paediatric theatres for PICU/PHDU staff.
Shift rotation of PICU staff onto adult COVID areas prior to use of PICU for admission of adult patients.
Daily support from adult regional critical care network.
Simulation and virtual training sessions to upskill non-AICU staff.
Daily clinical and non-management updates from local trust and international societies.
Simulation training by AICU team.
Training on AICU patient data management system with access to all adult guidelines.
Equipment
Challenges
Solutions
Medicines.
Dialysis fluids.
Imaging.
Airway management.
Ventilators.
PPE.
  • Regular discussions with pharmacy and AICU.

  • Network approach to transfer to another centre for RRT.

  • Two additional hand-held USS probes.

  • Adult trolleys including McGrath blades.

Ventilators.
PPE.
Dialysis fluids.
Airway management.
  • NIV ventilators repurposed for use.

  • London Fashion School staff tailored theatre drapes to gowns.

  • RRT planning or collaboration with regional dialysis centre at Northwick Park Hospital.

  • Reorganised paediatric airway trolley with adult equipment.

Ventilators initially loaned to AITU.
RRT.
Adult equipment storage.
Storage of medications.
Maintenance of sufficient supply of ventilators for paediatric admissions.
New CD cupboard.
Adult airways trolleys and central line trolleys.
Transfer to original AICU or RLH dialysis centre.
PPE.
Ventilators.
  • Specific donners and doffers for all pods.

  • PICU consultant shifts changed from 24 hours shift pattern to 13 hours resident shifts.

  • Changed all ventilators from anaesthetic machines to Draeger in adult pod.

Medicines.
PPE.
-AnaConDa product to save on syringe drivers and intravenous drugs.
Ventilators.
Dialysis fluids and RRT admissions.
Medicines.
Staffing.
  • Plans to repurpose neonatal ventilators and transport ventilators if necessary.

  • Leadership updates and planning for alternatives when in short supply.

  • Occupational health involvement to get directives on who and when to return to work.


Extra RRT machines sourced from industry and the fluids from the private sector.
Infusion pumps.
Airway management.
PPE.
  • Reprogrammed Pumps for adult volume.

  • Difficult airway trolley from AICU.

  • ANP, advanced nurse practitioners; ODP, Operating Department Practitioner; OSCE, Objective Structured Clinical Examination; PHDU, paediatric high dependency unit; PICU, paediatric intensive care unit; PPE, personal protective equipment; SHO, Senior House Officer; SpR, Specialist Registrars.