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Table 1 Summary of considerations and strategies to maintain ICU capacity and services

From: Preparing your intensive care unit for the COVID-19 pandemic: practical considerations and strategies

  Containment or alert phase* Pandemic or crisis phase*
Scenario Limited community spread isolated to individuals or clusters Sustained widespread community transmission
Key strategy Containment and preparedness Mitigation and containment
SPACE Designate an isolation ICU, with negative pressure AIIR
Rapid identification and isolation of suspected/known COVID-19 cases
Ensure access to rapid diagnostic testing (e.g. laboratory facilities)
Initiate planning for surge ICU bed capacity
  Utilise normal pressure ICU beds or existing monitored beds (e.g. OT, PACU, high dependency, endoscopy suites, emergency department)
  Alternative: cohort beds with physical barriers (e.g. curtains) in between patients
  Ensure timely step-down of stable patients with deisolation protocol
  Mass critical care: triaging protocol for patients with consideration for available resources, ethical principles, and public engagement
STAFF Staff segregation into ‘frontline’ teams
Implement strict infection prevention and control measures
Education of HCWs on infection control measures with just-in-time N95 fit testing
In situ, just-in-time simulation training with before-and-after multidisciplinary peer-review processes
Periodic re-training of HCW on infection control measures
Staff surveillance (e.g. temperature monitoring) and access to designated staff clinics
Ensure dissemination of timely and factual information and establish two-way communication
Provide helplines and psychological support, temporary staff quarters, gratitude messages from hospitals and public
Initiate ICU hands-on training for non-critical care nurses and ICU refresher courses for HCW using online materials and instructional videos
  Minimise unnecessary procedures and transport
  Increase manpower capacity by changing work structure (e.g. extra shifts or work hours) and restricting leave
  Suspend elective procedures and non-essential services
  Redeployment of HCW with critical care experience from other departments into ICUs
  Consider reducing nurse- and doctor-to-patient ratios
  Mass critical care: reassign non-intensive care HCW from other departments to support essential services, with ICU nurses providing a supervisory role
SUPPLIES Ensure adequate supply and stockpiles of PPE, essential consumables, medication, and equipment
Source for alternative supply channels for supplies and equipment; consider extended use of supplies/consumables where safe to do so and rationalise use of essential medications
Switch to single-use items (e.g. disposable bronchoscopes)
Segregate equipment (e.g. designated ultrasound machines)
Harmonise item purchase within hospital and clusters
Ensure adequate cleaning services and waste management capacity
  Consider extended or limited re-use of N95 respirators
  Consider alternatives to N95 respirators, e.g. PAPR
  Rationalise the use of N95 respirators (e.g. risk stratify by activity type)
  Obtain alternative sources of mechanical ventilators
  Utilise stockpiled transport ventilators if available
  Mass critical care: use alternative forms of respiratory support (e.g. NIV, HFNC) to replace invasive mechanical ventilation
STANDARDS Maintain clinical standards and principles of ARDS (e.g. lung protective ventilation, prone ventilation when appropriate)
Consider early intubation; avoid NIV in the absence of evidence-based indications
Adapt resuscitation and emergency procedural workflows to optimise patient safety and minimise risk of transmission
Identify ECMO referral centre, establish referral and transport workflows
Establish a hospital outbreak response command centre for effective communication and coordination
Inter- and intra-hospital teleconferencing to share experience and knowledge
Coordinate hospital ICU efforts with regional and national plans
Continue to engage patients’ relatives
Utilise public relations and communications resources to build public trust
  1. ICU intensive care unit, AIIR airborne infection isolation room, COVID-19 coronavirus disease 2019, OT operating theatre, PACU post-anaesthesia care unit, HCW healthcare worker, PPE personal protective equipment, PAPR powered air-purifying respirator, NIV non-invasive ventilation, HFNC high-flow nasal cannula therapy, ARDS acute respiratory distress syndrome, ECMO extracorporeal membrane oxygenation
  2. *The planned response should ideally be a phased or tiered response or a continuum-based response which evolves along with the impact of the pandemic