ICU

MANAGEMENT & PRACTICE

INTENSIVE CARE - EMERGENCY MEDICINE - ANAESTHESIOLOGY VOLUME 20 - ISSUE 1 -2020

COVID -19
Challenges
Challenges and Management in Italy and Lessons The Calm Before the Storm, K. Naidoo, D. Kloeck, L.
Learned, M. Cecconi Mathivha
From Hydroxychloroquine and Remdesivir to Plasma Personal Experience: 66 days in Wuhan, C. Wang
Administration, JL Vincent Masks in Intensive Care Units, A. Cornejo, A. Cunha
Adaptive Strategies for Intensive Care: The Brussels History of Pandemics, J. Poole
Experience, E. De Waele et al.
What COVID-19 Has Taught Me, A. Wong
Tracheal Intubation in the ICU, A. Higgs, M. Udberg, G.
Hopkin Intensive Care in the Coronavirus Era: Collective
Intelligence, H. Ksouri, S. Doll, G. Carrel, L. Hergafi, G.
An Adaptive Response, J. Nosta Sridharan
Ultrasound in Times of COVID-19, A. Wong, O. Thoughts on COVID-19, M. Malbrain, S. Ho, A. Wong
Olusanya, J. Wilkinson, C. McDermott
Overview of Nurse Assessment, C. Nicole
Nutrition for Critically Ill Patients with COVID-19, L.
Chapple, K. Fetterplace, E. Ridley Immersive Virtual Reality in the Intensive Care Unit,
C. Lynch, G. Jones

icu-management.org @ICU_Management
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COVER STORY: COVID-19 CHALLENGES

Adaptive Strategies for

Elisabeth De Waele
Intensive Care Department
Department of Nutrition
Universitair Ziekenhuis Brussel

Intensive Care During the

Brussels, Belgium

@ ElisabethWaele

Spread of COVID-19: The

Elisabeth.DeWaele@uzbrussel.be

Joy Demol
Intensive Care Department
Department of Nutrition

Brussels Experience
Universitair Ziekenhuis Brussel
Brussels, Belgium

Christophe Blockeel
Veerle Vloeberghs
Michel De Vos
Center for Reproductive Medicine This article describes the approach of the COVID-19 crisis at a tertiary Inten-
Universitair Ziekenhuis Brussel
Brussels, Belgium
sive Care Unit in Brussels, Belgium. Structured interventions and bottom-up
initiatives are highlighted, and practical examples given.
Peter Rosseel
MCR Consulting
Universitair Ziekenhuis Brussel

Lode Ruts Introduction of the ICU management as an intuitive

Department of Nutrition
Optimisation of medical response to response to the urgent challenge of the
Universitair Ziekenhuis Brussel
Brussels, Belgium no-notice events has been an important COVID-19 pandemic led to the development
focus of research in the field of disaster of seven building blocks that constitute
Daan Aeyels medicine (Debacker et al. 2016). However, the functional organisation of the ICU,
Natalia Aleksandrova evidence-driven development of medical with specific responsibilities assumed by
Brecht Bockstael
Marianne Borremans response protocols in novel domains of seven dedicated members of ICU staff. This
Femke Demolder
Marc Diltoer hospital medicine is time-consuming, and novel structure was established following
Helena Frederix time is lacking in unforeseen circumstances. a senior staff meeting on March 9, 2020,
Emilie Godinas
Steven Hendrickx The respiratory disease COVID-19 (CO-rona before the admission of the first COVID-19
Joop Jonckheer VI-2 rus D-isease 2019), caused by the novel patient in ICU. During that meeting, several
Wim Jonckheere
Theodorus Kalpakos severe acute respiratory syndrome (SARS) unmet needs were identified. Seven specific
Geert Liessens coronavirus (CoV), named SARS-CoV-2 or building blocks were identified and one
Stijn Lochy
Manu Malbrain 2019-nCoV, has resulted in thousands of single member of staff was appointed to
Glenn Meert infected patients and deaths worldwide since take responsibility of each element, with
Michaël Mekeirele
Ndagire Mutebi the end of 2019 (Livingston and Bucher no interference of responsibility across
Ducnam Nguyen 2020). Countries have adopted their own different elements. Crisis unit meetings
Pieter Jan Poortmans
Matthias Raes timeframe of risk-reduction strategies at were held on a daily basis, with room for
Michaël Rietz the level of their health service, reflecting feedback and discussion although owner-
Peter Rosseel
Joke Rossel their differential risk assessment strategies. ship of responsibilities was maintained
Nicolas Selvais In response to the COVID-19 outbreak, to reduce overlap of expenditure of time,
Jelle Smet
Bastiaan Sol the structure and organisation of health care energy and resources. The reshaping of
Evelien Spruyt at the hospital level had to be reconsidered the ICU management into a structure with
Marleen Vanhemelrijck
Alex Van Hoorn and action plans had to be developed seven key elements led by seven single
Domien Vanhonacker
Peter Van Londersele and implemented as new challenges kept commanders is depicted in Table 1.
Wim Verhelst emerging.
Intensive Care Department
Universitair Ziekenhuis Brussel This article describes the approach of Macro Level
Brussels, Belgium the COVID-19 crisis at a tertiary Intensive In line with hospital rules, the head of
Marc Noppen Care Unit in Brussels, Belgium. Structured the department has final responsibility
Chief Executive Officer interventions and bottom-up initiatives for the ICU. Alerted by the situation in
Universitair Ziekenhuis Brussel
Brussels, Belgium will be highlighted, and practical examples other countries, mainly Italy, the head
given. More specifically, internal reshaping of department had reported the status of

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COVER STORY: COVID-19 CHALLENGES

Macro level Operational Communica- Non-ICU environ-

management tion and staff ment (Coronary Care
well-being Unit, recovery room)

Internal and Medical and Communication Management of ICU

external stake- organisational strategies structure and medi-
holders contact command Staff physical cal support in remote
and psychologi- ICUs Table 2. Meetings Macro Level
cal well-being
Patients Family capacity and infrastructure at the ICU and
Care transmitted the specific needs to the CEO of
Head of Depart- Senior Staff Senior Staff Staff Member with the hospital, to the medical management,
ment Member Member Combined Profile the head of nursing and other hospital
directors, before the first patient arrived
Management Communica- People in need of critical (or invasive) treatment
of non-COVID tion support management due to COVID-19 disease (Table 2). He had
patients and training preliminary discussions with stakeholders
procedures outside the ICU to pave the way for the
dynamic adaptation process of the ICU
Medical and Back-up Management department, with an important focus on
practical manage- Members Crisis Nursing Depart- enhancement of capacity and expansion of
ment Unit ment medical and nursing staff. Additional beds
Confidential Logistics, Mate- were created by restraining non-urgent
Counselor rial, Drugs surgical procedures, which typically result
in 600 cardiac surgery and 400 brain
Senior Staff Non-medical Head Nurses surgery or brain trauma patients admitted
member to ICU each year. This was in line with the
hospital’s medical emergency plan where
Table 1. Organisational structure all non-urgent medical care, including
out-patient clinics and non-urgent out-
patient and in-patient interventions were
downscaled.
A nationwide direct line with peers from
other ICU’s across Belgium was set up in
order to exchange ideas and materials, both
medical and non-medical. The national
society of Intensive Care was contacted
and the website of the society (siz.be)
was activated as a platform of information.
Daily information regarding the number
of COVID-19 positive patients treated
in ICU, patients requiring mechanical
ventilation, ICU capacity and number of
available respirators had to be communi-
cated to the Belgian Government and daily
briefing sessions, chaired by the head of
department, were held to discuss the latest
Image 1. Briefing updated information provided by the seven
building blocks of the reshaped ICU and

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COVER STORY: COVID-19 CHALLENGES

and invasive procedures such as percuta- 3) In view of the risk of work overload
neous tracheostomy were introduced in due to the high number of patients for a
this accessory ICU. The operational lead limited number of specialised health care
of this ICU/CCU unit was delegated to providers (HCP), short and lean medical
an ICU member of staff with a combined management is mandatory.
cardiology/intensive care medical profile. Two days after the initiation of the
Within two days, the novel ICU/CCU unit ‘COVID-19 Plan,’ the chair of operational
was fully operational and the first patients management finalised a 15-page COVID-
were transferred to this remote ICU. These protocol that was made available for bedside
were non-COVID ICU patients with chronic use by HCP. Within this operational protocol,
critical illness or lower need of care. One treatment strategies in patients with respira-
ECMO-treated Influenza A patient was not tory failure were described, including nasal
moved to this ICU/CCU because the high oxygen therapy, ‘optiflow’ approach, the
complexity of care could not be guaran- decision not to use non-invasive ventilation
teed in a ‘new’ remote ICU. Expansion of because of too high viral aerosolisation
ICU beds was created on this macro level and rapid crush intubation, and ventilation
in agreement with other departments. in prone position. Other aspects of this
In the recovery room of the operating protocol included (Image 2):
theatre, a COVID zone was designed for • Sedation strategies;
infected surgical patients, and 3 ICU beds • Haemodynamics failure (drug manage-
were created. This enabled the transfer of ment);
non-COVID critically ill patients to this • Medical drug treatment, antivirals and
Image 2: Protocol new ‘remote ICU.’ Mixed ICU/recovery antibiotics, drug interactions;
staff was foreseen. A Medium Care unit • Nutritional treatment including enteral
to share this information with the entire was created when the first ICU patients nutrition in prone position and supple-
ICU staff (Image 1). were ready for step down or did not fulfill mental parenteral nutrition;
In view of the need to enhance the ICU indications for full ICU therapy. • Physiotherapy.
capacity, the development of a strategy to The tasks at macro level continued to Standard Operating Procedures (e.g.
create additional ICU beds was a primary evolve with new challenges during the endotracheal intubation) were developed
goal; indeed, further to the scenario in COVID crisis. to facilitate standard procedures and to
Italy where the impact of the spread of the reduce bedside time for HCP in a high-risk
disease was massive, we learnt that tripling Operational Management environment with high exposure manoeu-
the number of ICU beds would potentially The primary aim of redesigning the struc- vres. Paper versions of these documents,
be required. A capacity expansion algo- tural framework of the department was easily readable through plastic goggles
rithm was developed based on a “Phase to provide high quality, evidence-based and screens, were provided in the closed
1 to 5 Approach” in line with a growing medicine to critically ill patients, includ- COVID-19 treatment zones.
number of patients to treat: accordingly, ing those suffering from COVID-19. When Medical decision making on the use
it was decided to enter a higher-level compared with standard care, three key of resources (ICU units and medical and
phase with every series of 5 ICU COVID differences can be identified: 1) specific nursing staff) was the responsibility of the
patients admitted to ICU, which entailed evidence-based medicine is largely lack- operational manager. Dedicated areas for
the creation of a new 6 beds ICU unit with ing due to the novel aspect of the disease confirmed COVID-19 patients, patients
each phase, dedicated to the treatment of and lack of time for a ‘traditional’ RCT with uncertain COVID-19 status, and for
critically ill COVID-19 patients. So once driven research approach. 2) The harsh patients who tested negative for the virus
5 out of 6 beds were taken, the next unit bed-side working environment (risk of were created to ensure secure individual
was put into action. viral contamination by patients with very patient care (Image 3).
It was first decided to partially transform high viral load which necessitates extended Non-COVID ICU patients were trans-
the 6 bed CCU (Coronary Care Unit) to protective clothing) with priority to the ferred to newly created remote ICUs to
an almost full capacity ICU: mechanical safety of health-care practitioners does not create a ‘buffer zone’ in the main ICU. In
ventilation and monitoring were installed, allow certain ‘high-end’ medical procedures. the absence of COVID-19 positive infants,

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COVER STORY: COVID-19 CHALLENGES

paediatric ICU was moved to a ‘clean’ of senior ICU medical staff, an emergency
part of the hospital, more specifically the physician and a specialist depending on
operating theatres and recovery rooms of the condition.
the ART (Assisted Reproduction Technolo-
gies) department. Communication and Well-being
The operational manager took the respon- of ICU Staff
sibility to continuously screen the literature An Intensive Care Unit is a 24/7 staffed
for newly available medical information work environment with a very broad multi-
on the treatment of COVID-19 critically ill disciplinary nature. Medical doctors and
patients and to adapt the COVID-protocol highly qualified paramedical staff includ-
where appropriate. The COVID protocol was ing nurses, physiotherapists and dieticians
continuously adapted & updated. collaborate in an environment that is kept
The Ethical Committee of UZ Brussel safe and lean by logistic personnel and
drew up a guideline that determines who cleaning staff. At Universitair Ziekenhuis
will be admitted to the ICU in case of over- Brussel, the ICU counts approximately
capacity. Triage of patients was based on 200 staff in total.
the chance and quality of survival and was In an acute, rapidly changing setting,
Image 3: Units carried out by a team of experts consisting communication within this group is of
cardinal importance. A dedicated communi-
cation base was set up in the main waiting
area of ICU, strategically positioned and
liberated as family members were not
allowed during COVID crisis. Correct social
distancing was ensured by barring seats,
and floor marks were made to discourage
staff from gathering too closely during
briefing sessions.

Communication Base
Full responsibility for the building block
of communication was given to a single
member of staff, who physically manned
the communication base during regular
Image 4a. Communication Base
daytime working hours to gather questions
and provide answers to other members
of staff. Patient related communication
was developed besides communication
related to the “adaptive strategy” of the
ICU. Paper flipcharts were present and all
crucial information and procedures were
schematised on a single-page leaflet, to
make all ICU staff familiar with the new
series of interventions and rules, including
those staff whose knowledge of Dutch as the
official language in the hospital was poor.
As emerging information had to be
shared in a rapid and efficient manner, the
smart phone application WhatsApp® was
Image 4b. Visuals
chosen as the communication platform for

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COVER STORY: COVID-19 CHALLENGES

all people active in the ICU department. This ICUs when possible. To ensure that family who were proficient in foreign languages
represented a portable mode of commu- members were able to keep track of their were also recruited to the call centre in
nication where new information could be beloved ones, a dedicated Call Centre view of the ethnic background of our
shared instantly within a multidisciplinary was set up on day three. Volunteers from patients. Medical doctors from non-ICU
team (Nikolic et al. 2018). Visuals were a non-ICU department, more specifically departments in the hospital were relocated
attached to the ICU walls and posted on the midwives from the ART department, were to join this group, to liaise between ICU
WhatsApp platform.(Images 4a and 4b). recruited to man this Call Centre. For every physicians, the members of the Call Centre
Positive feedback from all different patient who was admitted to or discharged and the patients’ relatives.
levels of HCP confirmed the usefulness from the main ICU department, a separate
of this communication strategy. A laptop communication line was opened. As patient Psychological Support
was made freely available to all staff to numbers increased, all Digital Enhanced Because of the novel and invisible nature
check their emails or consult the hospital’s Cordless Telecommunications (DECT) in of COVID-19, this acute challenge put
information channels. This strategy was the ICU were redirected to this Call Centre a psychological strain on health care
copied to the two remote ICUs (CCU and from 8 am to 8 pm so medical and para- practitioners in the acute care setting
Recovery Room). medical staff could focus on patient care. of ICUs, where the background patient
Two days after setting up the COVID- Examples of communication with mortality rate is already 14%. In view
protocol at ICU, a specific WhatsApp group patients’ relatives through this Call Centre of this and other factors, ICU belongs
named “IZ COVID” (“Intensieve Zorgen include: to the top three of work environments
COVID,” intensive care COVID) was created • “Your father/mother/child/relative is with a high burn-out susceptibility
to include every ICU staff member. present in ICU n°13, 14, 15, 16, CCU, (Pastores et al. 2019). The harsh physical
WhatsApp Information shared in “IZ PACU, …;” circumstances (double layers of protec-
COVID” included: • “You can call up to three times a day tive clothes, face masks that injure nose
• Reallocation of ICU Units; to the following phone number for a and face, high temperature and difficult
• Recordings of daily ICU briefing short status update;” bedside manipulations of critically ill
(Movie); • “The medical doctor will call you COVID positive patients) all contribute
• Daily report on number of treated between 2 and 3 pm or in case of emer- to this mental pressure, even in a skilled
COVID patients; gency”; ICU crew. A Chinese cross-sectional
• Educational movies on how to wear • “We will call you with an informa- study suggests that health care workers
protective clothes in which areas. tion summary (stable situation, worse, exposed to COVID-19 have a high risk of
Examples of WhatsApp Feedback posted better) two times a day;” developing unfavourable mental health
within this group included: • “Who is the single contact person outcomes (Jianbo et al. 2020).
• Practical callouts (urgent need of anti- please, what is the link with the patient Therefore, the head of the ICU psychol-
fog spray for plastic helmets in COVID zone) and on which number can we reach ogist department was contacted, and a
• Temperature in COVID ICU rose to him/her?” ‘psychological support plan’ for HCP
26°C: urgent question if it was allowed • “Do you have any other questions? If was established. Two times per day,
to open the windows. we cannot answer them now we will psychologists were present in the coffee
A second WhatsApp group was created get back to you.” room where medical doctors, nurses and
for senior medical staff only, and a third Soon after the activities of the Call other HCP took a break from work in
group was created in which humoristic Centre had been announced through the COVID positive ICU’s. Although mainly
corona related jokes could be posted. This communication base, the first calls were small talks were done, several colleagues
served as a ‘mental break out’ for ICU made. A dedicated internal phone number had to be isolated with these psycholo-
practitioners (Amici 2019). More than 200 ‘9080’ was provided and shared. gists because of sudden crying or panic
jokes were shared between the members The Call Centre rapidly expanded to attacks. A specific email address for
of the group in less than 10 days. count five members of staff who manned psychological support was made avail-
the call centre seven days a week in shifts. able for all hospital staff, with optional
Call Centre After one week, eight call takers operated support outside the hospital.
Critically ill patients already hospitalised in in two shifts with one medical coordinator The psychiatric department was also
the ICU before the start of the pandemic and one link to remote ICUs and non- contacted, but because of a high number
were reallocated to newly created remote critical COVID-19 units. Members of staff of sick colleagues, they were not able

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COVER STORY: COVID-19 CHALLENGES

Team Spirit
At the start of the pandemic, the senior
management of ICU was assisted by a
specialist in communication techniques and
change management. This person proved
to play an important role in communica-
tion between members of staff, because
diplomacy might cease to exist in such
a stressful situation. The professional
approach of daily briefing sessions and
follow-up of the activities of different
working groups appeared instrumental
in reducing the risk of potential conflicts
among staff.
Image 5. Breathe

People Management
The head nurses of the ICU were engaged
to fulfill the following responsibilities:
• Management of day and night shift of
nurses, with attention to a fair spread of
the work load in the harsh environment
of the COVID-19 ‘war zones.'
• Incorporation of non-COVID ICU
nurses in the pool, to reduce workload
and to be prepared for drop-outs of ICU
nurses because of illness.
• Supervision and liaison with the
logistic department, facility care etc.
• Creation of new logistic areas where
drugs, disposables and other material can
Image 6. CCU/ICU
be reached by HCP working in COVID
and non-COVID zones.
to contribute. Relaxation and breath- recruited: cardiologists and nephrologists The availability of medical ICU staff
ing exercises were demonstrated and were given crash courses in mechanical was optimised: the rotation of clinical
shared on the communication platforms ventilation, inotropes and vasopressors fellows and junior medical directors to
(Image 5). and correct use of protective gear. A 24/7 other departments was discontinued,
surveillance was ensured, with direct which enhanced their presence in ICU.
Upgrading of Coronary Care Unit liaison with anaesthesiologists and ICU Cardiologists and nephrologists were
The increasing patient flow and need for physicians in case of specific technical recruited and were provided basic ICU
separation of COVID positive patients procedures or questions (Image 6). knowledge. Clear algorithms were made
urged the need for extra ICU beds. A with regard to when to reach out for
cardiologist with intensive care accredi- Non-COVID-19 Critically Ill assistance from medical ICU staff.
tation took the lead of this key element Patients Anaesthesiologists, as a second in line
and created three ICU beds in the former A single senior staff member was made medical specialist group, were invited to
CCU, which were supplemented with responsible for the medical care and reorganise their organogram in order to
three quarantine beds at a later stage. supervision of medical treatment by clini- be of assistance where needed. At a later
Signposting and logistics were provided. cal fellows and junior medical directors. stage, surgeons who volunteered to help
To be able to supervise ICU patients Quality of care for these patients was not were enrolled in the ICU step-down
in this remote area, additional staff was altered by the COVID-19 crisis. medium care to supervise critically ill

ICU Management & Practice 1 - 2020

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COVER STORY: COVID-19 CHALLENGES

patients in the post-acute rehabilitation support, creation of remote ICUs, non- fluidacademy.org), and is integrated within
stage of disease. COVID management, communication the not-for-profit charitable organisation
The organogram of medical staff support and people management/logistics. iMERiT, International Medical Education
was profoundly changed, with days off Capacity of ICU beds was raised from 30 and Research Initiative, under Belgian
scheduled randomly, in order to keep to 66 with a medium care up to 29 or 49 law. He is also a member of the medical
a 7/7 medical staffing present. Higher beds, medical and non-medical staff was advisory Board of Getinge (Pulsion Medi-
level in-house medical staff at night was recruited and crash course trained to occupy cal Systems) and Serenno Medical, and
organised, with three medical doctors relevant work slots, medical management consults for Baxter, Maltron, ConvaTec,
at central ICU, one cardiologist and one provided treatment protocols and Standard Acelity, Spiegelberg and Holtech Medical.
resident at the remote CCU/ICU and three Operating Procedures, internal and external The other authors have no potential conflict
anaesthesiologists to cover the operating communication with patients’ relatives of interest with regard to the content of
theatre and the remote recovery room – was established, newly developed logistic this review paper.
ICU. A junior staff member made daily algorithms were developed and the care
adaptations to the medical staffing in for non-COVID ICU patients remained
terms of need. optimal. This narrative overview can serve
Further assistance was offered sponta- as a template for other ICU departments Key Points
neously by medical doctors from various worldwide confronting no-notice events • A tertiary Intensive Care Unit in Brussels, Belgium
disciplines, who saw their own clinical such as the COVID-19 pandemic, to check shifted to a COVID-19-centric ICU by developing seven

activities downscaled. Non-medical assistance their current practice, develop new ideas building blocks: macro level management, operational
management, communication and psychological
was highly appreciated too. An otorhinolar- and copy whenever useful.
support, remote ICU’s, paediatric care, non-COVID
yngologist acted as supervisor for the call The writing of this article did not go management, and people management and logistics.
centre and assisted with practical issues. at the expense of valuable clinical work as • A single dedicated staff member had final responsibil-

Medical doctors from the ART Department the first author, an ICU physician, wrote ity over one block.
• The ICU was optimally prepared for the arrival of
were in charge with supervising the Call the manuscript while suffering from
a yet unknown number of severely ill COVID-19
Centre and with liaison. A urologist reached active COVID-19 disease and text editing patients, ready to upscale the care as patient numbers
out and was added to a list of volunteers. was done by helpful non-ICU colleagues. increased and ready to keep all staff involved, well
She was subsequently relocated to the Acknowledgements go to the colleagues informed and in the best possible shape to face the
threat.
out-patient clinic for sick HCP. of all kind who work and suffer in the
A professor emeritus of oncology took ICU department of Universitair Ziekenhuis
over the scientific work: ongoing studies Brussel and all HCP facing their duty in
at ICU were put on hold, contacts with these devastating times.
sponsors were made and administrative References
paperwork carried out by the data nurses. Amici P (2019) The Humor in Therapy: the Healing Power
of Laughter. Psychiatric Danub, 31(3):503-508.
Prospective data registration of COVID Conflict of Interest Debacker M, Van Utterbeeck F, Ullrich C, Dhondt E,
positive patients was launched. Elisabeth De Waele is an occasional Hubloue I (2016) SIMEDIS: a Discrete-Event Simulation
Model for Testing Responses to Mass Casualty Incidents.
member of the medical advisory board J Med Syst, 40(12):273.
Conclusion of Baxter Healthcare and consults for Baxter Jianbo L, Simeng M, Ying W et al. (2020) Factors Associ-
ated With Mental Health Outcomes Among Health
The approach of the COVID-19 pandemic at Healthcare, Fresenius-Kabi, Nutricia. She Care Workers Exposed to Coronavirus Disease 2019.
the ICU of Universitair Ziekenhuis Brussel receives research grants from the Belgian JAMA Netw Open, 3(3):e203976. doi:10.1001/jamanet-
workopen.2020.3976
was characterised by reshaping the struc- Government, KCE, and unrestricted grants
Livingston E, Bucher K (2020) Coronavirus Disease 2019
ture of the department and assignment of for clinical research. She is an Executive (COVID-19) in Italy. JAMA. doi: 10.1001/jama.2020.4344.

different novel responsibilities. The design Board member of the European Society of Nikolic A, Wickramasinghe N, Claydon-Platt D,
Balakrishnan V, Smart P (2018) The Use of Communica-
of the new structural ICU framework Metabolism and Clinical Nutrition ESPEN. tion Apps by Medical Staff in the Australian Health Care
comprised seven specific building blocks, She declares no conflict of interest to this System: Survey Study on Prevalence and Use. JMIR Med
Inform, 6(1):e9. doi: 10.2196/medinform.9526.
each chaired by a single dedicated ICU paper. Manu Malbrain is co-founder, former Pastores SM, Kvetan V, Coopersmith CM et al. (2019)
member of staff, who was made responsible President and current Treasurer of WSACS Workforce, Workload, and Burnout Among Intensiv-
ists and Advanced Practice Providers: A Narrative
for one of the following elements: macro (The Abdominal Compartment Society, Review. Academic Leaders in Critical Care Medicine
(ALCCM) Task Force of the Society of the Critical Care
level management, operational manage- www.wsacs.org). He is also co-founder Medicine. Crit Care Med, 47(4):550-557. doi: 10.1097/
ment, communication and psychological of the International Fluid Academy (IFA, CCM.0000000000003637.

ICU Management & Practice 1 - 2020