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1.1 All provinces and health regions are
encouraged to develop a surge strategy to cope with possible
dramatic increases in ICU demands from patients critically
ill from infection with H1N1. Timely activation of the surge
plan and policy are required to allow for a progressive
and potentially rapid increase in ICU capacity.
1.2 It is recommended that a stepped approach
to be developed to respond in a timely fashion to an evolving
threat and based on community H1N1 activity / hospitalizations
for H1N1 and ICU admissions for H1N1. It is difficult to
set exact thresholds and it is recommended that each jurisdiction
develop their own series of triggers. A surge plan should
distinguish between essential services that would need to
continue in the midst of pandemic and those that are deferrable.
1.3 Institutions should develop strategies
to ensure that there is adequate equipment and ICU personnel
for a surge of up to 200% in ICU occupancy.
1.4 A surge plan should incorporate the
following
- Consider both institutional and regional requirements
because patients may need to be transferred between institutions
in order to ensure care in the most appropriate setting.
- Take an accurate inventory of local ICU resources and
personnel.
- Delineate a clear trigger of the surge plan for each
hospital and region.
- The plan should be scalable and include planning for
an increase of ICU occupancy to 200%.
- Consider that the duration of ventilation and ICU care
for patients who have H1N1 infection may be longer than
that for patients who have other causes of ARDS.
- Develop or adapt/adopt admission/discharge criteria
for pandemic use to ensure consistency and optimization
of ICU flow.
- Consider 5 key elements: 1) Systems (command &
control, communication etc), 2) Staff (HR), 3) Supplies
(eg. medications, disposables), 4) Equipment, and 4) Space
(physical plant).
Ultimately a surge plan needs to consider 4 key elements
1) Systems (command & control, communication
etc)
2) Staff (HR)
3) Stuff (equip & supplies)
4) Space (physical plant)
Systems
1.4.1 Pandemic planning requires a concerted,
coordinated effort between all levels of government with
clearly defined roles, responsibilities and accountabilities.
A pandemic plan must be focused on a systems approach to
patient care to ensure timely, accurate dissemination information
about disease activity, impact upon hospitals and community
resources, and being able to link this information to hospital,
regional, provincial and ultimately, federal capabilities
and capacity. In a crisis, access to information and identification
of decision makers is of paramount importance. This process
needs to be developed in advance.
Human Resources
1.4.2
- All staff with ICU experience should be identified in
advance.
- Consider early focused retraining of individuals who
may be redeployed to an acute care setting.
- Staffing models that incorporate a hierarchal order
of command and patient care need to be developed.
o Consider increasing patient to nurse ratios (note that
this could be offset by having redeployed staff assist
with nursing care and tasks).
o Consideration of a model of ICU care that incorporates
a lead intensivist and administrator to coordinate resources
on a day to day and moment to moment basis.
o Consider redeployed staff to care for more stable patients
or assist with ICU staff.
o Surge plan should consider a model of ICU care with
one or more care teams comprised of a lead intensivist
who is supported by physicians who don't typically work
in ICU but posses skills that can be applied in critical
care (e.g. cardiologists, respirologists and anesthetists
who may be re-deployed to work in the ICU)
o Managing a large number of critically ill patients will
challenge care providers to deal with appropriately concerned
family members. A surge plan should also consider deployment
of social workers, spiritual care, and palliative care
to assist with the provision of comprehensive patient
care
o Ensure that the provision of standards of care is not
overlooked (this is particularly germane when the system
is stretched and non-ICU, HCW may be caring for critically
ill patients)
- DVT prophylaxis
- (Adoption of) Lung protective strategies
- Management of sedation, analgesia and delirium
- Stress ulcer prophylaxis
- VAP prophylaxis
- Vigilance for infection and initiation of broad spectrum
antibiotics with full septic work up when clinically indicated
- Central catheter infection prevention
- Early mobilization / physiotherapy
o Surge plan should consider a call roster that can cope
with care providers roster should be developed that includes
on-call staff to back-fill vacancies due to illness, provide
additional support if overwhelmed or burned out.
space
1.4.3 Health
authorities to determine where they will provide acute care
(including specialized services such as ECMO, HFO, NO),
chronic care (e.g. weaning), and care post ICU (rehabilitation
etc.)
- Develop protocols to move patients with early disease
out of small rural regions.
- Ensure that there is sufficient ability to transport
patients by land or air.
- Indentify the physical space for caring for critically
ill patients in advance and base the choices of space
upon functional requirements such as availability of ·oxygen
·suction
·medical gas
·electrical outlets
·physical space to work
·water for dialysis
Hospitals therefore need to develop an inventory of all
such equipped places in their hospital. They should then
have a plan as to the order in which ICU will be expanded
to these areas. The reader is referred to www.chestjournal.org
as it provides a helpful approach.
1.5 We recommend that graded responses
occur in relation to a series of triggers.
1.5.1
 Heightened
Awareness (increase in community H1N1 infection
rate)
It is recommended that this signal the need to initiate
regular teleconferences between public health officials,
government and hospital administrators. Command & control
should be established within the system but MUST also connect
with a regional/provincial authority as because individual
institutions do not have the ability to achieve adequate
situational awareness to make decisions like altering standards
of care or triage. It must be emphasized that enactment
of a system wide approach must occur to ensure that a series
of concerted local (hospital), provincial, and regional
(or local health authority) plans can be enacted and that
real time information is available to facilitate a coordinated
response to a potential escalation in a H1N1 threat. Hospitals
need to be linked into the big picture so such that they
are made aware of outside resources and can ask for help.
1.5.2
 Conventional
(Increase in hospitalizations for H1N1)
At this point consideration should be made to initiate surge
plans. When a surge plan is triggered, a clear line of authority
needs to be delineated. The type of authority will be institutional
dependent. The authority should be empowered to act on behalf
of the institution and be able to make decisions in a timely
manner. Authority for the pandemic surge should have both
administrative and clinical expertise.
Consideration should be made at this point to a review
of deferring elective procedures for programs that affect
ICU resources. A surge plan should evaluate and incorporate
priorities of the institution as it relates to other programs
and services (e.g. trauma, oncology, transplantation etc.)
that commonly have an impact upon ICU resource allocation.
Patients who can be discharged from the hospital should
be identified and provisions for increasing the number of
ICU beds should be provided.
1.5.3
 Contingency
(Increase in ICU admissions)
This level should consider more comprehensive administration
of a surge plan. Hospital employees that have been identified
(as described above) should be placed on notice that they
may be required to be redeployed to the ICU. All staff that
has ICU experience should be identified in advance.
In a crisis situation with altered nursing ratios and the
use of redeployed staff, the risk of error is perceived
to be high We recommend consideration of early focused retraining
of individuals who may be redeployed to an acute care setting.
We also recommend the institution of simple ICU protocols
with clear and well defined order sets to ensure that standards
of care are met and the potential for medical error reduced.
We recommend that wherever possible, redeployed staff care
for more stable patients or assist with regular ICU staff.
At this point there may be an abrupt increase in ICU demands.
If not already completed, the continuation of activities
by programs and services that impact upon ICU resources
should be prioritized on a day to day basis.
The impact of H1N1 on blood product availability must also
be considered. With increase in transfusion requirements
of a critically ill population and a reduction in donors,
regions may experience a significant shortage in blood products.
The relevance of this to surgical programs, oncology, trauma,
transplant and ICU needs to be considered.
1.5.6
 Crisis
(ICU resources are becoming saturated at one or more centres)
Full implementation of a surge plan should be enacted in
each region of the province. This will allow potential decompression
of the affected (sites). At this point each centre should
have redeployed their human resources to care for an increase
in hospitalized patients with provisions for reaching a
200% ICU capacity. Models of care and staff coverage / call
should be implemented in all ICU’s in the province.
1.5.7
 Triage
(ICU resources are saturated at a provincial / territorial
level with limited to no capacity to move patients to other
provinces or states.)
The decision to activate triage will likely lie with provincial
health officers. We recognize the ethical concerns associated
with the implementation of a triage program and the drastic
phase shift in care from a patient centered approach (do
what is right for the patient) to a public health approach
(do the best for the most). Several triage recommendations
currently exist. The model proposed by Ontario Health
Plan for an Influenza Pandemic (OHPIP) (see
Christian et al) has received the greatest attention
and centers upon the use of a Sequential Organ Failure Assessment
score with four main components: inclusion criteria, exclusion
criteria, minimum qualifications for survival and a prioritization
tool. Of some concern is that the proposed criteria ask
for review of a patient’s priority after a relatively
short period of ICU care. As many ICU survivors have long
ICU stays, the decision to limit care to an arbitrary duration
of time may have significant implications.
More recently the Hamilton Health Sciences Pandemic Planning
Committee (see
article by Kraus et al) have published an adaptation
of the triage protocol and have attempted to integrate additional
ethical values and other considerations such as a multiplier
effect (persons involved in the care of others – such
as health care workers – would receive priority during
triage). However, it is unclear if these workers, if they
become critically ill, would recover in sufficient time
to actually recuperate to the point of being able to return
to work and provide care. In addition approaches to triage
need to be widely adopted. Single centre / region approaches
to triage may lead to inequities in resource allocation.
Some have expressed concerns that the proposed suggestions
for modifying the triage process are controversial. Until
more widely adopted the medical criteria as defined in the
OHPIP document remain the primary guide for decision making
A recent publication from the Institute of Medicine is
recommended reading for those involved in pandemic planning.
This document provides current concepts and guidance to
assist public health officials, administrators, and professionals
in dealing with resource issues in the face of a pandemic.
A copy of the “Guidance for Establishing Crisis
Standards of Care for Use in Disaster Situations”
may be purchased or read on-line. Please go to the following
link www.iom.edu
Access to mechanical ventilators has been a significant
concern that the availability of mechanical ventilators
may represent the greatest rate limiting step. Although
the federal government is purchasing additional transport
ventilators, it is unclear if these ventilators will be
sufficient to meet the needs of the population during a
surge. Consequently Howe and all have developed a useful
guide to allocation of mechanical ventilators that is based
on the principles of care and resource management that was
outlined in the OHPIP plan.
The CCCS pandemic guidelines working group recommends that
the OHPIP critical care triage protocol and / or other published
triage protocols (see below) be used as a guide for regional,
provincial and federal pandemic planning during a surge.
It is important to emphasize that all patients will receive
care, irrespective of how they are triaged; but they may
not receive ICU supportive measures.
Other Useful Resources include:
Recommendations Developed by the American
College of Chest Physicians
AND
The
Utah Pandemic Hospital and ICU Triage Guidelines
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