Question 19

College Answer

Activate ICU/Hospital pandemic plan, if available.

Liaison / pandemic planning with other departments within the hospital, ambulance services, ICUs of other hospitals and state department of health.

Surveillance & early detection of influenza patients.

Increase ICU bed capacity. 
Increase ICU healthcare staffing levels.

Anticipated need for ICU equipment – identify where additional equipment can be resourced (ED, OR etc.)

Infection control measures to reduce the spread to other patients and ICU staff. Provision of antiviral prophylaxis / virus vaccine (if becomes available) for the staff. Establish real-time communication link with laboratory and healthcare administration.

Increased ICU bed capacity:

• Opening additional beds in existing non-commissioned physical critical care bed spaces.
• Defer elective surgery requiring post-operative ICU/HDU care.
• Progressively convert HDU beds to Intensive Care

• Identify potential additional capacity for ICU ventilated beds in alternative clinical areas such as recovery, CCU, peri-operative units and respiratory units.

• Discharge of suitable patients to other ward areas (with appropriate upgrade in medical/nursing support)

• Maximise the use of non-ventilatory strategies in care of ICU patients freeing up devices and equipment for patients for whom mechanical ventilation is essential

• Facilitate end-of-life discussions and decisions in those appropriate ICU patients assessed as not reaching a meaningful recovery
• Increase threshold for referral of patients for ICU from other hospitals
• Consider using available private hospital ICU capacity.

Increased staffing:

• Increase nursing staff shift length (e.g. 8 to 12 hour shifts)
• Expansion of nursing capacity by increasing casual, agency or bank staff support
• Cancellation of leave for medical and nursing staff

• Provision of anti-viral prophylaxis and virus vaccine (if becomes available) to staff to reduce staff absenteeism due to sickness
• Train staff from other non-ICU monitored areas to provide intensive care
• Secondment of additional medical staff from elective duties (e.g. anaesthesia)
• Change in nurse:patient ratio to provide intensive care
• Allocation of pregnant / immuno-compromised staff to” non-flu” patients
• Train staff in the use of PPE

Discussion

The question could be easily answered by a person who is intimately familiar with the summary statement of the Task Force for Mass Critical Care of the American College of Chest Physicians, as well as the recommendations of the European Society of Intensive Care Medicine Task Force for Intensive Care Unit Triage during an Influenza Epidemic or Mass Disaster.

The answer suggested below incorporates their recommendations, as well as the suggestions from the college answer, and the LITFL article on this topic which is heavily exam-oriented. The LITFL article in turn takes its inspiration from this 2006 MJA article, as well as published experiences from the recent H1N1 pandemic.

Preparation of disaster protocols

• Have a prepared protocol, a graded response plan
• Prepare to provide care at triple bed capacity
• Prepare to provide this care for at least 10 days

Management of ICU resources during the pandemic

How to create beds:

• Cancel elective surgery
• Transfer non-influenza patients to private ICUs
• Transfer stable patients to high dependency beds
• Urgently open extra ICU beds which are not funded:
  • Annex the recovery wards and CCU
  • Convert HDU beds to ICU
• Ration the use of mechanical ventilation for patients genuinely dependent on it, freeing up equipment

How to acquire more staff:

The major resource problem during the H1N1 pandemic in Australia was actually the availability of ICU-trained nurses.

• Cancel medical and nursing staff scheduled leave
• Increase working hours for medical and nursing staff
• Bring seconded staff back from secondment
• Increase proportion of casual nursing staff
• Appeal to locum agencies
• Train non-ICU staff to care for ICU-level patients
• Administer antiviral prophylaxis to decrease absenteeism

Daugherty, Elizabeth L., and Lewis Rubinson. "Preparing your intensive care unit to respond in crisis: Considerations for critical care clinicians." Critical care medicine 39.11 (2011): 2534-2539.

Devereaux, Asha, et al. "Summary of suggestions from the task force for mass critical care summit, January 26–27, 2007." CHEST Journal 133.5_suppl (2008): 1S-7S.

Horvath, John S., Moira McKinnon, and Leslee Roberts. "The Australian response: pandemic influenza preparedness." Medical journal of Australia185.10 (2006): S35.

Sprung, Charles L., et al. "Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster."Intensive care medicine 36.3 (2010): 428-443.

Harrigan, P. W., et al. "The practical experience of managing the H1N1 2009 influenza pandemic in Australian and New Zealand intensive care units." Crit Care Resusc 12.2 (2010): 121-130.