From Intensive Care to Step-Down Units: Managing Patients Throughput in Response to COVID-19.

QUALITY PROBLEM: The ongoing COVID-19 pandemic may cause the collapse of healthcare systems because of unprecedented hospitalisation rates. INITIAL ASSESSMENT: 8.2 individuals per 1,000 inhabitants have been diagnosed with COVID-19 in our Province. The hospital predisposed 110 beds for COVID-19 patients: on the day of the local peak, 90% of them were occupied and intensive care unit (ICU) faced unprecedented admission rates, fearing system collapse. CHOICE OF SOLUTION: Instead of increasing the number of ICU beds, the creation of a step-down unit (SDU) close to the ICU was preferred: the aim was to safely improve the transfer of patients and to relieve ICU from the risk of overload. IMPLEMENTATION: A 9-bed SDU was created next to the ICU, led by intensivists and ICU nurses, with adequate personal protective equipment, monitoring systems and ventilators for respiratory support when needed. A second 6-bed SDU was also created. EVALUATION: Patients were clinically comparable to those of most reports from Western Countries now available in the literature. ICU never needed supernumerary beds, no patient died in the SDU, there was no waiting time for ICU admission of critical patients. SDU has been affordable from human resources, safety, and economic points of view. LESSONS LEARNED: COVID-19 is like an enduring Mass-Casualty Incident. Solutions tailored on local epidemiology and available resources should be implemented to preserve efficiency and adaptability of our institutions and provide adequate sanitary response.