PLANNING FOR A PANDEMIC - A Guide To Intensive Care Units

Posted on 02-April-2020 at 02:50 PM

Dr. Aniruddha Chimote, Anaesthesiologist & Director, Hosconnn Consulting Services Pvt Ltd, drchimote@hosconnnconsulting.com

The need to plan and prepare for an infectious disease pandemic adds a whole new set of challenges to the practice of medicine. Though medicine has evolved phenomenally over the last 100 years, the emergence of the next great pandemic will severely affect our ability to care for massive numbers of patients with the traditional approaches with which we have become accustomed.

Any good pandemic response rests on three pillars

1.      Preparedness and Communication

2.      Surveillance and detection

3.      Response and containment

 The ability to respond to an increase in demand, which exceeds the normal, is referred to as surge capacity. This includes things such as push-packs (pre-packed supplies held in reserve to meet increased demand), overflow of patients outside of typical care areas such as mechanically-ventilated patients in the post-anaesthesia care unit (PACU) in addition to the intensive care unit (ICU), use of personnel typically assigned to other areas transferred to the ICU, and triage of both patient disposition and allocation of resources such as ventilators.

 MEASURES to reduce ICU demand

1.      Cancel all non- urgent elective surgeries in government hospitals and private hospitals in a staged manner in especially those surgeries which may require postoperative care in ICU/HDU, and emergency surgeries to be triaged and conducted using minimal theater infrastructure and planning for rest of the space for conversation into potential areas for HDU / ICU areas, theatre resources to be utilized cleverly for that means

 2.      Cooperative agreement with other health services to minimize unnecessary ICU admissions and limit ICU admissions for patients who require only expert ICU needs like mechanical ventilation/ moderate to high Vasopressor support , by making extended stays for rest of patients in HDU zones and step down to wards and early discharges with minimal hospital waiting periods. Nonphysical ICU involvement in rapid response calls which can be managed by medical or anaesthetic team in telephonic liaison with ICU experts.

 3.      Reserving ICU Admission for Patients Requiring ICU-Specific Interventions

 Patients who only require monitoring should be managed in alternate locations. ICU admission should be prioritized to those who require specific ICU interventions such as mechanical ventilation.

This may necessitate the following:

  • Extended stays in the Emergency Department or Recovery
  • Admission to areas capable of HDU level monitoring (e.g. CCU)
  • Additional support/supervision for ward staff to manage patients of higher acuity

 4.      ‘Non-ICU’ Involvement in Rapid Response and Medical Emergency Teams

Approaches may include:

? MET call attendance and involvement by home teams

? Delegation of MET leadership roles to the medical or anaesthetic services, with ICU providing a supervisory role

 5.      Proactive Consideration of Treatment Goals

There should be early consideration of treatment goals to avoid ICU/HDU referrals or admissions in patients who are more appropriately managed on the ward. This may be facilitated by ensuring that all patients have documented goals-of-care or equivalent completed upon hospital admission.

 6.      A centralized round the clock teleconference facilities for expert ICU input for hospitals running with non-expert teams

 MEASURES TO INCREASE ICU CAPACITY (INFRASTRUCTURE)

 All potential areas which can be converted to ICU zones should be identified and back up equipment for rapid conversion should be in place

all clinical areas with the physical infrastructure suitable to care for critically ill patients should be identified. These include (but are not limited to):

? Complex Care Units or other High Dependency Units

? Perioperative monitoring / recovery areas

? Coronary care units

? Uncommissioned or unstaffed ICU bays

? Decommissioned critical care areas (e.g. ‘old’ ICUs)

 The following are minimum requirements per bed for re-purposing an area for the care of critically ill patients

2 Oxygen outlets

1 Air outlet

2 Suction outlets (in extreme cases electrical & manual suction)

12 main electricity outlets with minimum of 1 outlet having UPS backup

Appropriate Physical monitoring

Portable Light source

 Equipment

 Each hospital should clearly quantify the current stock of equipment

This may include:

? Equipment from operating theaters / peri-operative environments

? Older but functional equipment not presently in use (e.g. old ventilators which can be operationalised by biomedical departments)

? Manufacturers and suppliers

? Hospital, state or national emergency stockpiles

? Jurisdictional procurement agencies

 The following equipment will be needed

 1. Ventilators; invasive and non-invasive

2. ICU Infusion pumps 

3. Monitors - invasive and non-invasive

4. Suction Apparatus

5. hand ventilating assemblies

6. Airway access equipment, including a device for management of the difficult airway

7. Vascular access equipment

8. Defibrillation and pacing facilities

9. Equipment to control patient temperature

10. Chest drainage equipment

11. Portable transport equipment

12. Specialized beds

13. Ultrasound for placement of intravascular catheters and for POCUS 

Other equipment for specialized diagnostic or therapeutic procedures (e.g. renal replacement therapy, intra-aortic balloon counter pulsation, echocardiography, extra-corporeal membrane oxygenation etc.) 

All current stocks of equipment for each hospital should be collected and should be available on a centralized registry from where resource allocation can be done as per the demand and government should have immediate access to agencies which could supply equipment in bulk. The logistic channels for procurement should also be kept in mind

Also back up equipment for potential areas which can be converted to ICU’s so the shortage should be in the list and arrangements for immediate ICU set up in those areas with equipment available on demand.

ICU Discharge Facilitation

The processes to expedite discharge from ICU should be implemented. These may include additional support for ward staff to manage patients of higher acuity, or rapid decanting of patients to areas with greater clinical oversight (e.g. neurosurgical HDUs). Coordinated processes need to be established with all stakeholders to ensure ward staff are appropriately supported. Organization-wide initiatives to optimize patient flow must be adopted, in conjunction with ICU-level efforts.

MEASURES TO INCREASE ICU CAPACITY (Work force and staffing) 

Due to potential workforce shortages, it is likely that non-critical care trained medical, nursing and allied health staff will have to assist in the care of intensive care patients. Ideally people in the younger age group with no comorbidities should be recruited for this purpose.

Training should include

 ? Proper use of PPE and infection control practices

? Supervision of staff and visitors donning/doffing of PPE

? Routine nursing care - turning, washing

? Re-supply, storage and inventory of equipment

? Medication delivery and checking

? Documentation

? Maintaining bed management and patient flow information

? Supporting essential pandemic research projects

 Additional Medical staff and they should be deployed according to their skill set levels

 ? Senior medical staff with critical care training, but not currently working in ICU

? Paediatric ICU medical staff

? Anaesthetic staff (due to a reduction in surgical activity)

? Junior medical staff with critical care experience

?Junior medical staff with no ICU experience for assisting in documentation and non clinical activities 

? Junior medical staff with special interest in research 

Allied Health

? Proper use of PPE and infection control practices

? Physiotherapists with previous critical care experience should be identified by hospitals and facilitated to return to ICU.

? Pharmacists with critical care experience should be identified and mobilized to assist the core ICU pharmacy staff.

? Social workers may need to be redeployed to assist with families isolated from their critically ill loved ones.

? Cleaning and Grade 2 staff with experience in ICU

? Suitable volunteers with appropriate training and supervision in PPE may also fill appropriate support roles (e.g. assisting at ICU reception, directing families). 

Communication 

Communication is crucial to the successful delivery of safe and effective clinical services.Information management plans should be established for effective and consistent dissemination of information to relevant stakeholders. These should include daily situation reports and regular updates on unit, organizational, regional and state responses.A variety of information dissemination methods should be considered to account for physical distancing needed for infection control purposes. These may involve video and teleconferencing, electronic communication and social media platforms.

 Effective lines of communication must be established to ensure that stakeholders are apprised of evolving clinical scenarios and changes in clinical practice guidelines and processes. ICU load and capacity must be measured in real-time and communicated to relevant in-hospital administrative and jurisdictional authorities. It is vital to track both patient outcomes and staff well-being. Specific stakeholders and considerations may include:

? Organizational chains of command

? State and national health authorities

? Clinical quality registries

? Inter-organization communications (e.g. for transfers)

? Inter-departmental communications

? Professional organizations

? Patients and families

? Staff

GUIDANCE FOR DECISION MAKING ABOUT ICU ADMISSIONS AND TREATMENT

A clear guideline for ICU ADMISSION SHOULD BE IN PLACE and in case of overwhelming demand for critical care services recommendation will be

 ? The decision-making process should be open, transparent, reasonable and inclusive of patients, their families, ICU and non-ICU staff.

? Similar ICU admission criteria should apply to all patients across all jurisdictions, and equally to patients with pandemic illness and those with other conditions.

? Senior Intensive Care medical staff, recognising available resources, should consider the probable outcome of the patient’s condition, the burden of ICU treatment for the patient and their family, patients’ comorbidities and wishes, and likelihood of response to treatment.

 Source: ISCCM, ANZICS

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