This document provides the framework to support the provision of intensive care services to adult patients during the COVID-19 pandemic. It should be used to inform local policies and procedures, which should be current and reviewed regularly.
The procedures described in this document apply to intensive care units (ICUs) within NSW public hospitals.
This guide provides direction to NSW local health districts (LHDs) for the delivery of intensive care services during the COVID-19 pandemic. This document supports the
NSW Health Influenza Pandemic Plan and the
NSW Health Services Functional Area Supporting Plan (NSW HEALTHPLAN).1, 2, 3
Conservative models of a large-scale influenza pandemic predict more than 170% utilisation of intensive care resources.4 Each facility should have its own plan to ensure that intensive care services are able to surge effectively and that equitable access is maintained.
ICUs have a key role to play in the organised response to COVID-19 in NSW. This document outlines the required response regarding:
Use of this guide and other policy documents will be underpinned by local factors. These include location and demographics; and service factors, such as leadership, governance, resources, policies and procedures.
This document is an update to the NSW adult intensive care services pandemic response planning document (last reviewed on 1 July 2021).
This guide is based on current evidence. It is supported by expert clinical consensus of a multidisciplinary team. It was developed in consultation with senior clinicians from the Agency for Clinical Innovation’s COVID-19 communities of practice (respiratory, emergency), the Clinical Excellence Commission (CEC) and the NSW Ministry of Health (Ministry).
There are currently four variants of concern, as determined by the World Health Organization: Alpha, Beta,Gamma and Delta. Australia is currently detecting the Delta variant. The Delta variant has increased transmissibility rates, severity, vaccine resistance and hospitalisation rates, compared with Alpha.6
Delta is also more common in younger people, compared with previous variants. Risk of hospital admission is approximately doubled in those with the Delta variant when compared with Alpha. This is particularly increased in those with five or more relevant comorbidities. This is impacting on the provision of intensive care services in NSW.6,7
A framework with clearly defined lines of communication will ensure the timely and accurate transfer of information and communication between intensive care service providers and pandemic response authorities. This should be used to support appropriate decision making and governance.
Key stakeholders have the following roles and responsibilities for planning the adult intensive care services pandemic response in NSW.
NSW Ministry of Health, NSW Agency for Clinical Innovation, local health districts (LHDs) and intensive care units within NSW public hospitals have defined roles and responsibilities for adult intensive care services pandemic response planning.
Information within the PFP should be updated by ICU staff at a minimum of every four hours, or as changes occur. This ensures it accurately reflects the situation within the ICU and enables site and LHD executives, and the Ministry to understand current capacity and resourcing in real time. The PFP should include:
During the pandemic, the incident controller will request all NSW ICUs to use the ICU Pandemic STEP and update the level as changes occur (or at least every four hours) in the PFP.
The purpose of the NSW Pandemic ICU STEP is to provide a framework that defines the impact of the pandemic on daily operations and the triggers to move to the next escalation phase. It enables facilities to employ strategies to manage critically ill patients during each phase of the pandemic.
Additional ICU bed capacity will be achieved by enacting local pandemic/disaster plans and considering:
Public Health Workforce Surge Guidelines(GL2014_003) have been developed to assist LHDs in understanding when and how to identify, recruit and utilise surge staff in the event of a pandemic. A team- orientated approach to staffing may need to be considered if lesser experienced staff are used in the ICU to support more skilled staff.9,10
These guidelines for surging staff in response to an event that exceed the existing capacity should be used in conjunction with the Adult intensive care workforce report in COVID-19 pandemic, and local ICU pandemic/disaster policies, with consideration to:
Each facility should have access to, and availability of:
The CEC guidance on infection control,
COVID-19 Infection Prevention and Control Manual, Respiratory Protection in Healthcare and
Fit test Assessor: Quick Reference Guide should be used by intensive care clinicians to support decision making around infection control.
ICUs should take measures to optimise communication with patients and families by:
During a pandemic, it will be important that consistent decisions are made regarding admission to ICU and continuing care when a meaningful recovery is unlikely.
Triage will be enacted at the same level across the state to promote equity of access of patients to intensive care. It is important that the triage principles to maximise access to ICU are used for all potential admissions; not just infection-related admissions.14 The process of triaging intensive care resources includes both the process of allocating resources and the process of withdrawal of resources, for all patients that may require intensive care during a respiratory pandemic.
Complex ethical and clinical treatment issues can occur. It may be necessary at some point to begin prioritising limited critical care resources to those with a need for treatment and those who are most likely to survive. Such prioritisation decisions would need to take account of all patients' probability of survival, as well as the availability of limited critical care resources.
The purpose of the NSW Pandemic ICU STEP is to provide a framework that defines the impact of the pandemic on daily operations and the triggers to move to the next escalation level. It enables facilities to employ strategies to manage critically ill patients during each phase of the pandemic.
The principles of this escalation plan are to:
Assumption: ICU patients that are medically cleared for discharge are transferred to the ward within 6 hours.
ACI Intensive Care NSW.
Consulted with senior clinicians, both medical and nursing, from NSW intensive care units through the adult and paediatric intensive care community of practice and the ICNSW Executive, ACI.
Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning, NSW Ministry of Health.
ICNSW, Intensive Care Community of Practice.
To support adult intensive care staff with surge in COVID-19 pandemic.
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