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Table 1 Critical care issues and solutions for COVID-19

From: Preparing for COVID-19: early experience from an intensive care unit in Singapore

IssuesPrinciplesSolutions
Infection control1. Avoidance of cross-contamination among HCW
2. Education and re-education on personal protective equipment and use of powered air-purifying respirators
3. Provision for workflows to cater to special groups, such as pregnant women with acute respiratory illness who are in labour
4. Enhanced surveillance for infection in HCW
5. Strong emphasis on good hand hygiene for all
6. Robust visitor screening and management
• A dedicated roster to segregate “clean” and isolation teams, and to provide for stand-bys
• Provision of clean scrubs for HCW to change into before duty; showering facilities at the end of shift
• Education and re-education on personal protective equipment and use of powered air-purifying respirators, especially for isolation teams
• Allow isolation teams to have a 2-week off-duty observation period (“wash-out” period), after every period of ward cover if manpower allows
• Mandatory reporting of twice daily temperature monitoring by all HCW
• Advance declaration of leave and overseas trips by HCW
• Screening questions are regularly updated as case definitions evolve over time, especially for known clusters of infection in the community
• Provision of thermal scanners at the doorstep to screen for fever
• Maintaining a hospital visitor log to allow for contact tracing and activity mapping of confirmed cases
Dissemination of information to HCW1. Robust system of dissemination of information (changing policies, workflows, etc.)
2. Email and meetings alone are insufficient to operationalize urgent changes on the ground
3. Clinical discussions of confirmed cases within the ICU community
• Utilization of secure and approved platforms such as institutional email and messaging applications to inform various job groups and teams of rapidly evolving workflows and policies
• Utilization of secure videoconferencing applications to hold inter-institution and inter-department meetings and educational sessions
• Utilization of secure and approved applications such as messaging and videoconferencing applications to conduct clinical discussions of cases and the sharing of experience
Resuscitation and code blue response1. Provide clear guidelines on personal protective equipment and use of powered air-purifying respirators in ISO wards and normal wards during resuscitation
2. Provide inter-professional simulation of resuscitation scenarios for suspected or confirmed cases
• Simulation practice with personal protective equipment and use of powered air-purifying respirators will help identify gaps in the wards and prepare ISO teams for such scenarios
• Simulation with limited team members per scenario, for example, 4 members per team, to allow acclimatization of HCW to perform resuscitation in smaller teams
• Checklists for preparation of drugs and pre-prepared trolleys for equipment, for intubation, line setting and other procedures, to minimize staff movement and enhance efficiency
• Creative ways to improve communications during resuscitation, such as utilization of a printed “Call Airway Team” card for difficult intubations, using a communication whiteboard in the patient room and using walkie-talkies to relay messages to staff outside the room for equipment and help
Advanced ICU services1. To provide clear thresholds for transfers of deteriorating cases for ECMO
2. To provide efficient and safe delivery of ICU bronchoscopy
• Early transfer of deteriorating cases is recommended. Provision of thresholds for transfer and workflows for non-ECMO centres
• Use of disposable bronchoscopes for bronchoscopy and percutaneous tracheostomy
Psychological stress and burnout of HCW1. To provide emotional support, encouragement and appreciation to HCW
2. Reduce stigmatization of HCW by ill-informed members of the public
• Special provision of meals and drinks to boost morale; laundry service for used scrubs
• Provision of regular updates of the local situation and status by the government and institution leadership
• Frequent encouragement of HCW by divisional heads and senior leaders via emails, messaging apps and social media platforms, allowing staff to remain engaged
• Timely articles and courageous stories of frontline staff
• Appropriate media coverage of HCW at the frontline to increase empathy and reduce stigmatization
  1. ECMO extracorporeal membrane oxygenation, HCW healthcare workers, ICU intensive care unit