Introduction
The exponential rise in COVID-19 cases in New York City at the beginning of the pandemic in 2020 created an immense strain on the city’s resources. Montefiore Medical Center, the largest academic hospital in Bronx County, faced an unprecedented surge in admissions, necessitating creative solutions. Multiple healthcare bodies recommended the suspension of elective surgeries and clinic visits1, 2 and Montefiore followed suit, freeing its ambulatory surgical centers (ASCs), including the Hutchinson Metro Center (the Hutch), a standalone campus within the Montefiore system. The Hutch comprises 12 floors, 2 of which are dedicated to ASCs with 16 operating rooms (ORs). Following the US Food and Drug Administration’s approval of repurposing anesthesia machines as ventilators, the decision was made to convert the Hutch ASC into an intensive care unit (ICU) facility.
Conversion discussions initiated on March 19, 2020, and the unit opened for patient transfers 5 days later, accommodating 14 ICU beds and 60 floor beds. The Hutch campus functioned as a flexible overflow adjunct to the main hospital campuses, accepting primarily less critically ill patient transfers until its closure on April 10th. While the literature does describe the conversion of ORs to ICUs within hospitals,Reference Chawla, Peters and Groves3–Reference Uppal, Silvestri and Siegler5 hospital wards to ICUs,Reference Xiong, Hu and Huang6, Reference Zappella, Dirani and Lortat Jacob7 and non-healthcare facilities into ICUs,Reference Brady, Milzman and Walton8–Reference Singh, Ambooken and Setlur10 none explore ASC-to-ICU conversion. Future pandemics are likely to occur and ASCs are uniquely equipped to permit their rapid conversion to ICUs, allowing the quick expansion of critical care services in stressed healthcare networks.Reference Dodds11, Reference Høiby12 Therefore, documenting the Hutch conversion and establishing a comprehensive ASC-to-ICU conversion framework is crucial for future preparedness.
Narrative
First, the feasibility of converting the Hutch into an ICU was assessed. The facility comprised 16 ORs and 60 post-anesthesia care unit (PACU) beds, allowing for the creation of up to 16 ICU beds within the ORs and 120 potential floor beds in the PACU, as each PACU bed was equipped with 2 oxygen and suction sources. Because the Hutch was intended to serve as an overflow site within the Montefiore network, proximity to other campuses was an important consideration. The nearest hospital, the Jack D. Weiler Hospital, was located 1.3 km (0.8 mi) away.
Next, structural logistics were assessed. The local oxygen supply was the primary limiting factor in expanding the Hutch’s capacity to meet ICU-level care demands. The existing infrastructure supported approximately 1,200 outpatient-level patients per month but was limited to a total of 16 hours per day of high-flow oxygen consumption.Reference Shaparin, Mann and Streiff13 Continuous oxygen provision for ventilated patients would have rapidly depleted available resources within days; therefore, the oxygen farm was upgraded in size. In addition, 50 size-200 oxygen cylinders were ordered to cover bedside needs.
Supplies and technological logistics were addressed next. Personal protective equipment (PPE) was a chief concern due to the nationwide shortage. A policy of one disposable N95 respirator daily for staff was implemented. Pharmacy capacity was limited to a standard inpatient medical-surgical floor list of medications available at Weiler, functioning as a supply hub. Existing ventilators in the OR were assigned for ICU-level use, while PACU oxygen sources were assigned for non-critical use. Imaging machinery included 2 portable X-ray machines, 5 C-arm X-ray machines, and 1 ultrasound machine. Medication machinery included multiple Pyxis machines, 2 med carts, and 2 crash carts. Routine laboratory operations collected by on-site phlebotomists and OR nurses were sent to the main hospital campus for processing every few hours. Blood gas samples were analyzed at the bedside. Call bells, phone extensions, overhead paging, and a master phone number list were all created to maximize telecommunication efficiency.
Clinical criteria for transfer were created next, which revolved around the limitations of the Hutch. This included various interventional services that the Hutch could not provide such as hemodialysis and a lack of many on-site consultation services. (see Table 1). No formal inclusion criteria were made but generally included positive laboratory results for COVID-19, a filled census at established Montefiore hospitals, and patients who required intubation. A transfer workflow was then created based on those criteria and transportation availability (see Figure 1). Any patients requiring greater than 6 liters of oxygen were sent to the ICU. Patients who decompensated after transfer were then sent back to other campuses for higher-level care.
Transfer criteria at the Hutch
Workflow of the Hutch transfer process, from initial screening to patient bed assignment.
Lastly, staffing was addressed. Attendings, primarily from the departments of anesthesiology and internal medicine, staffed the Hutch ICU, and residents across several surgical and medical departments joined. Residents were given a 2-week rotating schedule; every 2 weeks, they would either work in an ICU setting or have a rest period.Reference Shaparin, Mann and Streiff13 This not only provided time to rest but also allotted time for potential quarantine. Residents also provided vital education to non-ICU nurses and ancillary staff. Meanwhile, attendings followed a 12-hour shift or 24-hour subspecialty pager call schedule 3-4 times weekly. All OR and non-OR areas needing potential emergency intubation were continuously staffed in-house. Critical care-trained attendings were assigned to critical care duties and also led didactics and pertinent protocols. An interventional radiologist was also assigned to cover radiology needs. All other consultations were done via e-consult.
A hurdle identified early in the scheduling process was the limited availability of nurses with ICU-level training. Nurses at the Hutch were accustomed to ambulatory care and outpatient services. Certified registered nurse anesthetists (CRNAs) were essential in aiding this gap. Nighttime schedule gaps were filled in with pediatric licensed practical nurses. Pain management subspecialty nurses completed competency training for medical-surgical services.
Two respiratory therapists were available to assist with ventilation as needed. One case manager was assigned to perform social work duties. A pharmacist and four clerical staff were reassigned to the Hutch. Transportation was assessed to manage the delivery of PPE, medications, laboratory samples, food, staff, and patients. It was stratified into 3 primary groups: patients, urgent and emergent labs and medications, and a recurrent deliveries of nutrition and clothes (linens, gowns, towels, blankets).
Discussion
The Hutch ICU opened on March 24 and shortly after, the COVID-19 census peaked on April 3. By April 10, the Hutch closed. This conversion suggests that ASCs can serve as flexible overflow assets during pandemics to expand ICU-level care. We outline the major steps for ASC to ICU conversion used at the Hutch using the 4 S’s approach of disaster medicine: systems, structure, stuff, and staff.Reference Hick, Koenig and Barbisch14
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1. Systems: Assessing the community’s needs and establishing an appropriate conversion timeline based on the urgency of the public health emergency is the first step. A key factor to consider for the ASC is proximity to tertiary hospitals to facilitate patient transfers and resource sharing.
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2. Structure: Because ASCs are outpatient facilities, structural resource deficits are to be anticipated when transitioning to an inpatient setting. The facility’s oxygen capacity and distribution sources should be identified early and expanded as necessary, as these will determine the number of ICU beds that can be safely supported. Water capacity should be assessed if hemodialysis is planned. Facilities should ensure their electrical systems can sustain continuous use and consider supplemental generators, as used in other temporary ICUs during the COVID-19 pandemic.Reference Candel, Canora and Zapatero9 Building occupancy codes and fire safety protocols should be updated.
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3. Stuff: Reliable supply chains for PPE, medications, and ventilators must be established, either through distribution from nearby hospitals or by developing independent procurement pathways. Anesthesia machines can be repurposed as ventilators when ICU ventilators are limited, enabling a faster transition.
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4. Staff: Structured schedules for attending physicians, residents, and nursing staff must be developed. Ancillary services are vital to successful ICU operations and must be secured early. An intensivist-to-patient ratio greater than 1:14 has been associated with poorer staff well-being and patient outcomes.Reference Ward, Afessa and Kleinpell15 Similarly, nurse-to-patient ratios exceeding 2.5 increase mortality,Reference Ward, Afessa and Kleinpell15 while ratios of 1.7 or lower improve outcomes.Reference Checkley, Martin and Brown16 To address staffing shortages, clinicians and nurses from non-critical care specialties can be rapidly trained and redeployed. Cross-training and maintaining safe patient-to-provider ratios are crucial for sustaining quality care during surge conditions.
There were several limiting factors during the transition. The biggest challenge was expanding the oxygen delivery infrastructure to meet the 24-hour demands. Similarly, repurposing anesthesia machines for 24-hour use presented significant challenges. Future efforts would benefit from maintaining stockpiles of ventilators and establishing contingency contracts for supplemental oxygen delivery to bridge the gap during upgrades to the main oxygen farm. Staffing was a critical hurdle addressed by using CRNAs in place of ICU nurses and implementing an e-consult system using Montefiore network specialists. For the future, prearranged emergency contracts with nursing locum tenens agencies would help circumvent this challenge. Hemodialysis was not feasible due to the large water requirements. Unfortunately, the temporary nature of the Hutch prevented robust outcome analysis. Nonetheless, the project succeeded in expanding ICU capacity.
Conclusion
The rapid conversion of an ambulatory surgical center into an ICU at Montefiore Medical Center was a successful example of disaster response during the COVID-19 surge. Despite infrastructure and staffing limitations, the facility functioned as an effective overflow ICU within 5 days of planning. This experience offers a replicable framework for future health crises. Embedding flexible strategies into disaster preparedness plans will enhance health system resilience and improve responsiveness during future pandemics.
Author contribution
Vitaliy Lasiychuk: Wrote and edited the final drafts of the manuscript. Created figures.
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- Jordan Eidlisz: Wrote and edited the final drafts of the manuscript. Created figures.
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- Kateryna Slinchenkova: Edited drafts of the manuscript.
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- Avinash Malaviya: Wrote first drafts of the manuscript, conducted interviews with hospital leadership, and constructed the initial framework of the project.
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- Jessica A. Dekhtyar: Edited the final drafts of the manuscript and created figures.
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- Lissen Simonsen: Contributed to initial conception of project, edited final drafts. Also was part of the hospital leadership during the ASC-ICU conversion.
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- Curtis Choice: Contributed to the initial conception of the project and edited the final drafts. Also was part of the hospital leadership during the ASC-ICU conversion.
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- Frank C. Aroh: Contributed to the initial conception of the project and edited the final drafts. Also was part of the hospital leadership during the ASC-ICU conversion.
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- Rebecca B. Siegel: Edited drafts of the manuscript.
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- Jeffrey Freda: Contributed to the initial conception of the project and edited the final drafts. Also was part of the hospital leadership during the ASC-ICU conversion.
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- Elilary Montilla Medrana: Edited drafts of the manuscript.
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- Adela Aguirre-Alarcon: Edited drafts of the manuscript.
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- Kathryn A. Breidenbach: Contributed to the initial conception of the project and edited the final drafts. Also was part of the hospital leadership during the ASC-ICU conversion.
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- Karina Gritsenko: Edited drafts of the manuscript.
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- Naum Shaparin: Contributed to the initial conception of the project and edited drafts. Also was part of the hospital leadership during the ASC-ICU conversion.
Competing interests
None.
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