1. 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

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

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 Or… 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
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

8. Mortality rate

9. 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?

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DH Draft guidance for IC in the ICU during pandemic flu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
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

16. Referral, admission and discharge criteria
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 Derogations
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