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

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 Or… 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

Mortality rate

Realistic & sustainable 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Standard infection control principles Droplet precautions Higher level protection for aerosol generating procedures DH Draft guidance for IC in the ICU during pandemic flu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

Referral, admission and discharge criteria 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 Derogations 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