COVID19 : Ventilators alone are not enough to treat patients in critical condition
The COVID-19 disease has infected more than one million people globally in just under five months. According to a report from the World Health Organization (WHO), approximately 80% of those infected will exhibit mild symptoms, 15% will be considered as severe and will require oxygen support whilst 5% will be deemed critical and require ventilators. Harvard epidemiologist Marc Lipsitch estimates that between 40% - 70% of the world’s population will be infected by COVID-19.
If Prof Lipsitch’s words were to be believed, we will be heading towards 3.12 billion infections worldwide, conservatively speaking. Out of that number, if 5% were to require ventilators, we will be looking at a whopping 156 million ventilators eventually! Let’s hope that at any one time, approximately 5% of the infected population would require ventilators, which brings us to 7.8 million ventilators in active use. That is still a big ass number.
The race to ramp up ventilator production
I applaud the automotive industry for stepping up to the plate in the race to build more ventilators. Medtronic, a Dublin-based ventilator maker is sharing the design specs for a basic ventilator model as it discussed a manufacturing partnership with Tesla. Dyson has also joined the rush to make more ventilators for the UK. Such collaborations in the middle of a public health crisis are commendable. However, these “new players” must still adhere to the same rules and regulations as the rest of the medical device sector. Unless major changes are implemented on the slow-moving regulatory frameworks, it will take months before newly made devices by these new players get to market.
Are ventilators alone enough to treat critical COVID-19 patients?
Clearly, we need more than just ventilators. A critical COVID-19 patient also needs the essential drugs, hospital beds and ICU facilities, skilled and highly trained nurses and highly responsive ventilator field service engineering teams to ensure a high uptime.
Supply chain and distribution
Ventilator supply chains must be robust and responsive and manufacturers need to ensure that their supply of raw materials is not disrupted. With the artificial scarcity of air services due to the grounding of passenger aircraft, lightweight manufacturing hubs will have to be setup closer to demand points in order to be responsive. An MIT-based team is currently working on a rapid deployment of an open source, low-cost ventilator which can make near shoring ventilator production a reality, hopefully soon!
Critically ill patients require to be intubated and given strong sedatives and pain medications such as propofol and fentanyl before they are attached to a ventilator. According to a recent NPR report, “the US may get more ventilators but run out of medicines for COVID-19 patients.” Therefore, the production of ventilators must also be in line with the production of the necessary drugs. Vizient, a US-based healthcare performance company noted a significant drop in fill rates for critical drugs due to COVID-19. While most hospitals have not yet run into critical drugs shortage, the prospect of having to come face to face with the grim reality is very real once the buffer stock runs dry.
Critical Care Nurses
While ventilators and critical drugs are important, so too are the critical care nurses or ICU nurses. These are very skilled healthcare personnel that have been trained for a range of highly technical interventions such as invasive and non-invasive ventilation, cardiac monitoring, sedation management and many more. You cannot simply redeploy say, an ER nurse to replace a critical care nurse. At the most, s/he can assist the ICU nurse.
It typically takes about two years to be trained and certified as an ICU nurse and looking at the current situation, there needs to be more rigorous and accelerated programmes to produce more ICU nurses quickly.
There have also been calls to encourage critical care nurses to come out of retirement to join the COVID-19 fight and some bravely did so. While these retired nurses may have more experience, they are generally older and may be more at risk of contracting and becoming seriously ill from COVID-19.
When COVID-19 hit Wuhan, China increased ICU capacity by over 1,000 beds in two weeks via the building of a new hospital, but this is not likely to be possible in any other country. Managing a COVID-19 ICU patient is far more complex since it requires the patient to be isolated and staff to wear PPE. Such additional setups are needed even before a bed may be commissioned for COVID-19 use. Apart from doctors and nurses, seamless coordination with the cleaning crew will be also required to ensure that beds and proximate areas are properly disinfected between patients and procedures.
Repairs and Maintenance
The extended use of ventilators will inadvertently require responsive maintenance teams and well stocked spare parts inventory. The issue is exacerbated with a plethora of different ventilator models that use non-standard parts. Hopefully, ventilator manufacturers will adopt common standards for parts and servicing protocols to widen the access to biomedical engineers who are brand-agnostic. Creative use of 3D printing may be able to meet the demand for critical parts as well. From the technology standpoint, IoT and Asset Management software with Machine Learning capabilities may be introduced to make better predictions of impending breakdowns.
In summary, ventilators alone are not enough to treat critical COVID-19 patients. We also need essential drugs, highly skilled critical care nurses, ICU beds and highly responsive maintenance teams. Existing regulatory frameworks must be reviewed urgently to ensure that ventilators produced by non-traditional makers are able to get to market quickly. COVID-19 is a global pandemic and needs to be resolved beyond national boundaries. As individuals, we should continue do our part to minimize the risk of infecting the more vulnerable in our population.
“Ventilators alone are not enough – the NHS needs staff” by Alastair McLellan, https://www.hsj.co.uk/workforce/ventilators-alone-are-not-enough-the-nhs-needs-staff/7027160.article
“4 ways to avoid a COVID19 ventilator crisis” by Kathirgugan Kathirasen, https://www.freemalaysiatoday.com/category/opinion/2020/03/28/4-ways-to-avoid-a-covid-19-ventilator-crisis/
“James Dyson designed a new ventilator in 10 days. He’s making 15,000 for the pandemic fight” by Nada Bashir, https://edition.cnn.com/2020/03/26/tech/dyson-ventilators-coronavirus/index.html
“MIT-based team works on rapid deployment of open-source, low-cost ventilator” by David L. Chandler, MIT News Office, http://news.mit.edu/2020/ventilator-covid-deployment-open-source-low-cost-0326
“The regulations non-medical manufacturers may need to overcome to tackle ventilator shortages” by Jamie Bell, https://www.nsmedicaldevices.com/analysis/uk-ventilator-regulation-coronavirus/
“U.S. May Get More Ventilators But Run Out Of Medicine For COVID-19 Patients” by Melissa Block, https://www.npr.org/2020/04/04/826961777/u-s-may-get-more-ventilators-but-run-out-of-medicine-for-covid-19-patients
“Critical care nurses will need our support as COVID-19 cases rise” by Nicki Credland, https://rcni.com/nursing-standard/opinion/comment/critical-care-nurses-will-need-our-support-covid-19-cases-rise-158836
“Becoming an ICU Nurse: Education and Career Guide” by Christa Terry, https://www.noodle.com/articles/becoming-an-icu-nurse-education-and-career-guide
“I’m an ICU doctor. The NHS isn’t ready for the coronavirus crisis” by Tim Cook, https://www.theguardian.com/commentisfree/2020/mar/03/icu-doctor-nhs-coronavirus-pandemic-hospitals