SCCM | United States Resource Availability for COVID

For icyu strategy option. Default options in the ICU: widely used but insufficiently understood

Preparing intensive care units ICU is an integral part of any pandemic response.

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  • Care for Critically Ill Patients With COVID | Critical Care Medicine | JAMA | JAMA Network

In this review, we discuss the key principles and strategies for ICU preparedness. We also describe our initial outbreak measures and share some of the challenges faced.

To achieve sustainable ICU services, we propose the need to 1 prepare and implement rapid identification and isolation protocols, and a surge in ICU bed capacity; 2 provide a sustainable workforce with a focus on infection control; 3 ensure adequate supplies to equip ICUs and protect healthcare workers; and 4 maintain quality clinical management, as well as effective communication.

While these incidence rates are difficult to interpret and may be overestimated due to differences in availability of diagnostic testing, surveillance resources, and outpatient management of patients with mild illness, it appears that many patients who do develop critical illness do not survive. ICUs will be simultaneously challenged on multiple fronts. These include resource limitations, infection control, protection of healthcare workers HCWsand adaptation of services to a rapidly evolving pandemic situation.

ICU resources in Lombardy, Italy, are also reported to be overwhelmed [ 7 ]. Clearly, the ability to maintain sustainable critical care services is a key consideration for all healthcare systems.

United States Resource Availability for COVID-19

In this article, we aim to describe the critical care response in the largest academic tertiary medical centre in Singapore. The main targets to achieve are to 1 prepare and implement rapid identification and isolation protocols, and a surge in ICU bed capacity; 2 provide a sustainable workforce with a focus on infection control; 3 ensure adequate supplies to equip ICUs and protect HCWs; and 4 maintain quality clinical management, as well as effective communication.

Table 1 Summary of considerations and strategies to maintain ICU capacity and services Full size table Key strategies at different phases of a pandemic When faced with sporadic cases or defined clusters in the community, maximising containment to reduce community impact and buy time for preparations is the key priority.

Within healthcare institutions, this is achieved with rapid identification and isolation of suspect or confirmed COVID cases, and strict infection control measures to minimise intra-hospital transmission and prevent incapacitation of essential services.

If national and regional containment measures fail, healthcare systems are at risk of being rapidly overwhelmed [ 7 ]. In the event of sustained widespread community transmission, emphasis then shifts towards supporting essential hospital services, for icyu strategy option as critical care and emergency care, to maximise mitigation whilst maintaining containment efforts.

The planned response is a continuum and will vary based on the scale and severity of the pandemic [ 14 ]. AIIRs are kept at negative pressure relative to surroundings and ventilated with at least 6—12 air changes per hour Fig.

In our centre, all patients are screened at the emergency department, inpatient wards, and outpatient clinics. Based on screening questionnaires travel and contact historysymptoms, and preliminary investigations chest radiographspatients are stratified into COVID risk levels and admitted into open wards, cohort beds, single room beds, or negative pressure isolation rooms, respectively.

Diagnostic testing is performed on specimens pharyngeal swabs, or lower respiratory tract samples if applicable for SARS-CoV-2 with real-time reverse transcriptase—polymerase chain reaction RT-PCR —we emphasise that healthcare systems need to ensure that there is adequate infrastructure and facilities to enable rapid testing.

This complicates identification of cases and contact tracing. In Singapore, comprehensive and coordinated contact tracing is done at the hospital for icyu strategy option national level to maximise containment efforts [ 21 ].

Default options in the ICU: widely used but insufficiently understood

For icyu strategy option suspect case definition is currently based on a combination of travel and contact history, and presence of respiratory illness [ 22 ]. Each healthcare system will need to constantly evolve their protocols and suspected case criteria to balance safety, yet optimise resource utilisation [ 2324 ]. During a pandemic, however, significantly higher surge ICU capacity is needed and critically ill patients may need to receive for icyu strategy option outside of a traditional ICU [ 14 ].

The planned response will depend on available resources, and trigger targets for activation of each phase of response should be defined early.

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  • SCCM | United States Resource Availability for COVID

Alternative sites to care for critically ill patients must be identified early. Beyond this, patients will be cared for in existing ICU beds.

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We have also made comprehensive plans for the use of existing monitored beds e. It is important that ICU bed planning should take into consideration the availability of oxygen ports, compressed air supply, clean water, and drainage systems [ 18 ].

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Concurrent timely discharge to step-down care areas is critical and enables ICU resources to be used effectively.

By this time, all elective surgeries and non-essential services need to be suspended so that resources can be quickly redirected. This may mean that high-flow nasal cannula HFNC therapy or non-invasive ventilation NIV is used to mitigate acute ventilator shortages, even though they do not constitute preferred management due to infection control concerns aerosolisation of respiratory droplets.

Therapeutic strategies for critically ill patients with COVID-19

Triage of critically ill patients may become necessary to prioritise ICU resources, and ethical principles must be carefully considered to ensure just and equitable delivery of care for all patients [ 252627 ]. These criteria should ideally be objective, transparent, and publicly disclosed.

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Authorities should engage the community in this process so that public trust exists when it is most needed [ for icyu strategy option262729 ]. STAFF: maintaining service capabilities and protecting healthcare workers Establish infection control measures Infection prevention and control is essential to protect both patients and HCWs [ 30 ]. Critical care HCWs are at high risk considering the higher exposure dose from aerosol-generating procedures and longer periods of patient contact.

As with other respiratory viruses, it is likely that SARS-CoV-2 spreads predominantly through contact direct or indirect and droplet transmission.

Care for Critically Ill Patients With COVID-19

Though faecal shedding of the virus has been demonstrated, faecal-oral transmission remains unproven [ 34 ]. Strict adherence to droplet and contact precautions including hand hygiene, eye protection, and safe donning and doffing of personal protective equipment PPE will be the main defences against transmission.

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Table 2 Summary of infection prevention and control measures Full size table Airborne transmission with respiratory viruses remains controversial [ 37 ], although it is likely that any airborne transmission with COVID will be opportunistic in nature [ 38 ].

Powered air-purifying respirators PAPRs are alternatives, but careful doffing and disinfection is necessary to prevent self-contamination [ 41 ]. HCWs must doff and dispose of PPE safely within designated areas, with equipment and environmental decontamination enforced. Other potential aerosol-generating procedures e.

Nevertheless, we discourage nebulised therapy metered dose inhalers with or without a spacer are used instead and use closed in-line suction for tracheal aspiration in our centre.

With no clear mortality benefit with HFNC therapy in respiratory failure, our preferred management is conventional oxygen therapy and early intubation [ 42 ].

Abstract Background The ongoing coronavirus disease COVID pandemic has swept all over the world, posing a great pressure on critical care resources due to large number of patients needing critical care. Statements from front-line experts in the field of intensive care are urgently needed. Methods Sixteen front-line experts in China fighting against the COVID epidemic in Wuhan were organized to develop an expert statement after 5 rounds of expert seminars and discussions to provide trustworthy recommendation on the management of critically ill COVID patients.

However, we do recognise that in the event of severe ventilator shortages, these modes of respiratory support may have to be utilised—ideally with strict infection control measures.

In our institution, mechanical high-efficiency particulate air HEPA or pleated hydrophobic filters are fitted to mechanical ventilators at expiratory ports, as well as NIV mask and bag-valve-mask interfaces Fig. It should be noted that airway resistance and circuit dead space may be increased as a result [ 44454647 ]. Connections should be tightly fitted to avoid disconnections during movement. Dead space and circuit resistance will increase with the use of filters.

A standard HME heat and moisture exchanger white arrow is attached at the Y-piece of the breathing circuit. HCWs should be taught to inspect, disinfect, and dispose of PPE safely, and periodic refresher re-training is required to ensure staff readiness and proficiency.

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In our centre, an online critical care refresher course was organised indicators for binary options turbo non-intensivist physicians, with voice-annotated lectures on ICU management and instructional videos on ventilator set-up and troubleshooting.