6Initial Organisational Problems Multiple well meaning sources of guidanceIsolation roomsH1N1 Testing frequency/timescalePPE masksAvailabilityFittingStaff groups
7Pandemic Declared by WHO 11/6/09 NHS/Government responsesContainment to Treatment PhaseHealth Boards- Pandemic Planning GroupsMultiple specialtiesClinicians and managers and external agenciesRegular meetingsDouble intensive care capacity
13ICU Planning: Double Bed Capacity AssumptionsNon-essential surgery stoppedSpread into theatre recovery areasNon-ICUAnaesthetists freed upRob staff from theatres/recoveryRob anaesthetic machines
14ICU Planning Staff: Training in ICU and others Equipment: PPEConventional VentilatorsOscillatorsHaemofiltersAt risk groupsChildren in adult ICU’s ?Pregnant women – obstetric responses in ICU’sTriaged ICU admission/withdrawal???
15Triaged ICUChristian M et al. CMAJ 2006Taylor B et al. JICS 2006
16Triaged ICUPrioritisation for Critical Care Admission based on SOFA score and Clinical OpinionMichael D. Christian et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ • November 21, 2006 • 175(11) |
17ICU Planning: Scotland Scottish Critical Care Delivery GroupICU CliniciansCollation of Escalation PlansCollective responses and mutual supportEquipmentCapacity managementTriage responsesScottish Intensive Care Society Audit GroupBed numbers: Temporary and EstablishedRapid dissemination network to all ICU’sResearch liaison: SwIFT
18SwiFT inclusion criteria All patients (adult or paediatric) who were either:H1N1 swine influenza (suspected or confirmed) patients referred and assessed as requiring critical care; ornon-H1N1 patients referred and assessed as requiring critical care (under usual/ non-pandemic circumstances) but not admitted to a critical care unit in your hospital.
27ECMO A pregnant woman with swine flu is getting the "best possible treatment“after being flown toSweden, according to theScottish health secretary.Nicola Sturgeon said she hadhad a very rare reaction to theH1N1 virus.Sharon Pentleton, 26, who iscritically ill, was taken toCrosshouse Hospital, inKilmarnock, last week, whereshe had been put on aventilator.She was transferred toStockholm on Thursdaybecause no beds wereavailable in the UK for theprocedure she needed.
28ECMO: The CESAR Trial Lancet 2009; 374:1351-63 Online publication Sept 09Study July 01- Aug 06180 patients randomisedTransfer to Glenfield for consideration for ECMOVBest Conventional Management at Referral Centre(no protocol)
29ECMO: The CESAR Trial Lancet 2009; 374:1351-63 Composite outcome death or severe disability at 6 months:ECMO 37%Conventional Treatment 53% p=0.03
30ECMO: The CESAR Trial Lancet 2009; 374:1351-63 Group Differences and Confounders 90 “ECMO” patients5 died pre or in transit17 did not have ECMOECMO group significantly more likely to have:Low volume low pressure ventilation strategyLonger time with LPLV strategySteroidsMARSIncomplete follow up 3 control patients
31Set Up New ECMO Centre(s)?? “…there is insufficient evidence to provide a recommendation forextracorporeal membrane oxygenation use among patients withrespiratory failure resulting from influenza. However, cliniciansshould consider extracorporeal membrane oxygenation within thecontext of other salvage therapies for acute respiratory failure.”(Crit Care Med 2010; 38:1398 –1404“…clinicians at hospitals that do not have an ECMO program, it wouldbe advisable to establish institutional guidelines to identifyECMO-eligible patients in a timely manner and to establish arelationship with an ECMO capable institution to facilitate safeinterhospital transport”
42H1N1 Outcome 4 patients still in hospital ANZICS hospital mortality 17% but 16% still in hospital
43Survival status at end of critical care DeadDeadDeadAliveAliveAlive
44ICU/Critical Care Profile Equipment/Resources H1N1 Aftermath“UK response to H1N1 pandemic was highly satisfactory, independent review says”BMJ 2010;340:c3569The review, by Deirdrie Hine, a former chief medical officer for Wales, says that preparations, including stockpiling drugs and plans to buy up to 132 million doses of vaccine, were "soundly based in terms of value for money, reflecting the inherently low cost of vaccination in relation to the value of lives saved….. changes need to be made to ensure that critical care services can cope with a more severe pandemic should it occur. “ICU/Critical Care ProfileEquipment/ResourcesFuture disasters and pandemics