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Assembly Line ICU: what the Long Shops taught us about managing surge capacity for COVID-19
  1. Callum Oakley,
  2. Craig Pascoe,
  3. Daivd Balthazor,
  4. Davinia Bennett,
  5. Nandan Gautam,
  6. John Isaac,
  7. Peter Isherwood,
  8. Tracie Matthews,
  9. Nick Murphy,
  10. Tessa Oelofse,
  11. Jaimin Patel,
  12. Catherine Snelson,
  13. Carla Richardson,
  14. Jeremy Willson,
  15. Fiona Wyton,
  16. Tonny Veenith,
  17. Tony Whitehouse
  18. on Behalf of the QEHB COVID-19 Response Team
    1. Department of Critical Care and Anaesthesia, Queen Elizabeth Hospital Birmingham, Birmingham, UK
    1. Correspondence to Dr Tony Whitehouse; Tony.Whitehouse{at}


    Objectives To safely expand and adapt the normal workings of a large critical care unit in response to the COVID-19 pandemic.

    Methods In April 2020, UK health systems were challenged to expand critical care capacity rapidly during the first wave of the COVID-19 pandemic so that they could accommodate patients with respiratory and multiple organ failure. Here, we describe the preparation and adaptive responses of a large critical care unit to the oncoming burden of disease. Our changes were similar to the revolution in manufacturing brought about by ‘Long Shops’ of 1853 when Richard Garrett and Sons of Leiston started mass manufacture of traction engines. This innovation broke the whole process into smaller parts and increased productivity. When applied to COVID-19 preparations, an assembly line approach had the advantage that our ICU became easily scalable to manage an influx of additional staff as well as the increase in admissions. Healthcare professionals could be replaced in case of absence and training focused on a smaller number of tasks.

    Results Compared with the equivalent period in 2019, the ICU provided 30.9% more patient days (2599 to 3402), 1845 of which were ventilated days (compared with 694 in 2019, 165.8% increase) while time from first referral to ICU admission reduced from 193.8±123.8 min (±SD) to 110.7±76.75 min (±SD). Throughout, ICU maintained adequate capacity and also accepted patients from neighbouring hospitals. This was done by managing an additional 205 doctors (70% increase), 168 nurses who had previously worked in ICU and another 261 nurses deployed from other parts of the hospital (82% increase).

    Our large tertiary hospital ensured a dedicated non-COVID ICU was staffed and equipped to take regional emergency referrals so that those patients requiring specialist surgery and treatment were treated throughout the COVID-19 pandemic.

    Conclusions We report how the challenge of managing a huge influx of patients and redeployed staff was met by deconstructing ICU care into its constituent parts. Although reported from the largest colocated ICU in the UK, we believe that this offers solutions to ICUs of all sizes and may provide a generalisable model for critical care pandemic surge planning.

    • critical care
    • crisis management
    • hospital medicine

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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    • Collaborators The QEHB COVID-19 Response Team: Abby Ford, Alejandro Barrios, Andy Johnston, Anwar Shah, Bill Tunnicliffe, Julian Bion, Brian Pouchet, David Hume, David Riddington, Deborah Turfrey, Dhruv Parekh, Gregory Packer, Harjot Singh, Ian Ewington, John Kelly, Kaye England, Laura Tasker, Mansoor Bangash, Mav Manji, Mike Knowles, Mohammed Arshad, Neil Abeysinghe, Nicholas Talbot, Nilesh Parekh, Phillip El-Dalil, Randeep Mullhi, Ravi Chauhan, Ravi Hebballi, Richard Browne, Sam Denham, Sandeep Walia, Shraddha Goyal, Steffen Kroll, Sue Sinclair, Tom Clutton-Brock, Tomasz Torlinski, William Tosh, Zahid Khan

    • Contributors All authors contributed to the preparation, collation of data and writing of the paper. All authors approved the final paper. CO, CP, NG, TV and TW conceived the paper. CO and TW edited the paper prior to submission.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement The data that support the findings of this study are available from the corresponding author, TW, upon reasonable request.

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