Was the management of massive influx of critical COVID-19 patients adequate in the Paris area?

In their letter to the editor, Foucrier et al. describe the way the spring pandemic episode of COVID-19 was managed in the Paris area [1]. From the point of view of the Regional Health Agency (Agence régionale de santé Ile-de-France), bed management, increasing ICU capacity and interregional transfers allowed to face the massive flow of critical COVID-19 patients. This is a quite optimistic view considering the time course of daily ICU admissions and of ICU beds availability they report. Increased ICU bed availability begun only at the time when ICU daily admissions initiated a reflux. In addition, no direct relationship has been established between both indicators by these authors. Furthermore, the decrease of the latter is slower than the increase of the earlier. This gap can be related to at least three factors including underestimating the kinetics of spread of the pandemic, delay in ICU beds increase and lack of anticipation of increasing medicine beds for patients who do not require ICU admission.

At the time of lockdown and suppression of non-urgent surgery in France, on the 17^th of March 2020, pandemic kinetics was known from other countries, even though the data could be biased [2]. On the 20^th of March 2020, the French Ministry of Health anticipated a 14 days mean ICU length of stay and a 10 days mean post-ICU length of stay (Ministère des solidarités et de la santé. Besoins en réanimation et réponse capacitaire. Message d’Alerte Rapide Sanitaire. 20/03/2020). It does not take into account the wide individual variations conditioning the effective length of stay in ICU.

At the same time, the French Ministry of Health recommended to increase ICU beds even in recovery rooms and operating theatres and to create post-ICU beds. Unfortunately, the latter was not organised and the earlier was only gradual contributing to the time gap illustrated by Foucrier et al. With regard to the increase in ICU beds, private clinics were prepared for COVID-19+ patients admission before the 24^th of March, as shown by a nationwide survey among 176 of them and 14% in the Paris area (http://www.snarf.org/docs/EnqueteSNARF-COVID19_16-24mars2020.pdf Accessed on the 18^th of October 2020). Between the 16^th and the 24^th of March, nearly 90% of scheduled surgery was cancelled. In 74% of clinics it was anticipated either to create or to increase the number of ICU beds, at a time when 76% of public hospitals ICUs were not yet considered as overwhelmed. Despite this, only 27% admitted COVID-19+ patients during this period. A better coordination between hospitals and clinics could have prevented from interregional transfers of critical patients. In addition, although not documented, early opening of post-ICU beds would have increased the availability of ICU beds by increasing patient turnover as soon as life threatening conditions are under control. In this specific context, private clinics that cancelled scheduled surgery were asked to contribute to such a strategy in the late phase of the pandemic increase, as related by one of them [3].

Such acute medicine beds can easily be created from surgical beds not in use as outlined in Italy [4], within 24 hours [3], as they require reduced material resources compared to ICU beds. Personals can easily be relocated from both the surgical ward and operating theatres and recovery rooms, with little additional training. In France, such transformation requires administrative authorisation by the Regional Health Agencies, in order to have the necessary financial support.

At the time of a second COVID-19 wave, and in the perspective of recurrent COVID-19 episodes, it is therefore necessary to anticipate mobilisation of all facilities, including private clinics, with graded levels, in order to avoid any delay in adaptation of health services and critical patients transfers outside their region.