Managing critical care facilities

1. Managing critical care facilities Pandemic Flu – Planning Scotland’s Health Response, 5th June 2007, RCPE Dr Sarah Ramsay Consultant Anaesthetist Western Infirmary, Glasgow

2. Global National (DoH, SEHD etc) NHS Scotland Boards Local ICU groups Individual Hospitals Contingency planning

3. 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.

4. 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

5. Spectrum of illness Pandemic influenza • As seasonal flu? • Excess cases & deaths Or… • Younger adults affected? • Primary viral pneumonia? • Cytokine storm  multiple organ failure?

6. Patient subgroups • Elderly • Paediatrics • Obstetrics • Immuno-compromised

7. Predictions for Scotland 17% of the Scottish population <15 years old

8. Mortality rate

9. 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?

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

11. Increasing staffing • Remember impact of staff sickness • Profile current staff • Identify reserve staff • Engage in advance • Train & maintain • Ensure staff confidence

12. Risks of unfamiliar staff in ICU • Clinical errors • Infection control failures • Fatigue • Stress

13. Additional staff • Appropriate key skills in intensive care • Supervision • Protocols & guidelines • Infection control • Self protection • Prevention of HAIs • Rosters • Support and communication

14. 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infection control principles • Droplet precautions • Higher level protection for aerosol generating procedures DH Draft guidance for IC in the ICU during pandemic flu

15. Aerosol generating procedures Common in ICU:Intubation, physio, bronchoscopy, suctioning, nebulisers, tracheostomy care, NIV • 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

16. Managing demand Referral, admission and discharge criteria • Work with other specialities (A&E, respiratory, infectious diseases)

17. 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

18. Managing demand Triage decisions • Who & who not to admit • What to start and not start? • When to stop? • National ethics framework in development • Transparency

19. 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?

20. Picking up the pieces • Exhaustion • Deaths • Backlog • Further wave(s)

21. Flu in the ICU • Important role for ICU • Exact disease unclear • Escalation realistic and sustainable • Staff confidence vital • Integrated and co-operative preparedness planning