Table 1 Summary of considerations and strategies to maintain ICU capacity and services
| Â | 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 | ||
| Â | Utilise normal pressure ICU beds or existing monitored beds (e.g. OT, PACU, high dependency, endoscopy suites, emergency department) | |
| Â | Alternative: cohort beds with physical barriers (e.g. curtains) in between patients | |
| Â | Ensure timely step-down of stable patients with deisolation protocol | |
| Â | 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 | ||
| Â | Minimise unnecessary procedures and transport | |
| Â | Increase manpower capacity by changing work structure (e.g. extra shifts or work hours) and restricting leave | |
| Â | Suspend elective procedures and non-essential services | |
| Â | Redeployment of HCW with critical care experience from other departments into ICUs | |
| Â | Consider reducing nurse- and doctor-to-patient ratios | |
| Â | 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 | ||
| Â | Consider extended or limited re-use of N95 respirators | |
| Â | Consider alternatives to N95 respirators, e.g. PAPR | |
| Â | Rationalise the use of N95 respirators (e.g. risk stratify by activity type) | |
| Â | Obtain alternative sources of mechanical ventilators | |
| Â | Utilise stockpiled transport ventilators if available | |
| Â | 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 | ||