Managing critical care

facilities

Dr Sarah Ramsay

Consultant Anaesthetist

Western Infirmary, Glasgow

Pandemic Flu – Planning Scotland’s Health Response, 5th June 2007, RCPE

Contingency planning

• Global

• National (DoH, SEHD etc)

• NHS Scotland Boards

• Local ICU groups

• Individual Hospitals

Spectrum of illness

Seasonal influenza

• Extremes of ages

• Exacerbation of other co-morbid conditions

• Secondary bacterial infections

> primary viral pneumonia

• Rare: myocarditis, GBS, encephalitis, etc.

Spectrum of illness

NB…

• 10-25% of CAP patients require ICU

• ~ 50% require other organ support

• ICU stay longer than non respiratory conditions

• Mortality ~ 30%

– Increased if delay prior to ICU admission

Spectrum of illness

Pandemic influenza– As seasonal flu?– Excess cases & deaths

Or…– Younger adults affected?– Primary viral pneumonia?– Cytokine storm multiple

organ failure?

Patient subgroups

• Elderly

• Paediatrics

• Obstetrics

• Immuno-compromised

Predictions for Scotland

25% attack rate over 4/12 1,271,000

0.37% fatality rate 4,700

0.55% hospitalised 7,000

10% of adults need ICU 520 ICU cases

Average ICU stay 10 days

Peak ICU bed occupancy 120%

17% of the Scottish population <15 years old

ICU beds required, varying mortality (25% attack rate)

0200

400600800

10001200

14001600

1 9

17

25

33

41

49

57

65

73

81

89

97

10

5

113

Days of pandemic

0.37%1.00%

1.50%

Mortality rate

Increasing capacity

Realistic & sustainable

• Identify current HDU/ICU capacity• Identify additional capacity• Reduce elective work• Remember…

– Non-flu ICU patients– Transport of critically ill patients– Paediatric cases?

Increasing capacity

• Bed spaces• Ventilators• Piped gases• Drugs & supplies• Other equipment• PPE• Most important = staff

Increasing staffing

• Remember impact of staff sickness

• Profile current staff

• Identify reserve staff

• Engage in advance

• Train & maintain

• Ensure staff confidence

Risks of unfamiliar staff in ICU

• Clinical errors

• Infection control failures

• Fatigue

• Stress

Additional staff

• Appropriate key skills in intensive care

• Supervision

• Protocols & guidelines

• Infection control– Self protection– Prevention of HAIs

• Rosters

• Support and communication

Containment and infection control

• Education –staff, patients & visitors

• Exclude / restrict ill workers & visitors

• Cohort affected patients; cohort staff

• Appropriate infection control precautions

– Environmental infection control

– Standard infection control principles

– Droplet precautions

– Higher level protection for aerosol generating procedures

DH Draft guidance for IC in the ICU during pandemic flu

Aerosol generating procedures

• Minimise occurrence– Closed circuits, minimise breaks, filters

• Maximise safety– Use full garb including FFP3 masks

– Minimum number of staff present

– Preferably in a negative pressure side room

– Consider extended use of PPE in busy units

Common in ICU: Intubation, physio, bronchoscopy, suctioning, nebulisers, tracheostomy care, NIV

Managing demand

Referral, admission and discharge criteria• Work with other specialities (A&E, respiratory,

infectious diseases)

DoH clinical guidelines for HDU/ICU transfer

• Primary viral pneumonia• Severe CAP (CURB-65

score of 4-5)• General indications:

– persistent hypoxia on maximal O2

– progressive hypercapnia– severe acidosis (pH < 7.25)– septic shock– exacerbation of underlying

co-morbid disease

Managing demand

Triage decisions

• Who & who not to admit

• What to start and not start?

• When to stop?

• National ethics framework in development

• Transparency

Strange times…

• Indemnity

– For unit staff

– For reserve staff

• Derogations

– EWTD

– Targets waiting lists, standards of care

• Duty of care of individuals & institutions

– Conscientious objectors?

Picking up the pieces

• Exhaustion

• Deaths

• Backlog

• Further wave(s)

Flu in the ICU

• Important role for ICU• Exact disease unclear• Escalation realistic and

sustainable • Staff confidence vital• Integrated and co-operative

preparedness planning