Background
Containment or alert phase* | Pandemic or crisis phase* | |
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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 |
Key strategies at different phases of a pandemic
SPACE: critical care beyond the ICU
Designating an isolation ICU
Rapid identification and isolation of suspected or confirmed cases
Maintaining ICU surge capacity
STAFF: maintaining service capabilities and protecting healthcare workers
Establish infection control measures
Infection prevention and control measures | |
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General measures | Develop robust risk stratification criteria Actively identify and isolate patients suspected to have COVID-19 Effective contact tracing Rapid laboratory diagnostic testing Care for suspected or confirmed cases in negative pressure AIIR—patients to wear face masks until transfer to AIIRs Strict hand hygiene and standard precautions Staff PPE requirements For all patients: droplet and standard precautions, with additional airborne precautions when performing aerosol-generating procedures For suspected/known COVID-19 patients: droplet, contact, and airborne precautions Fit testing for all staff using N95 respirators Staff training (and re-training) for appropriate use, donning, and removal of PPE, with pictorial guides and videos where applicable Stockpile PPE and consumables for infection control Single-use items for patients (e.g. disposable blood pressure cuff) Disinfect shared equipment after use Provision of (disposable) staff scrub suits in isolation wards Appropriate handling of medical waste Hospital issued guidelines for infection prevention, including handling of patient specimens and care of the deceased patient Staff segregation and physical distancing Centrally tracked staff surveillance (e.g. temperature monitoring) and access to designated staff clinics Reduce face-to-face encounters with patients (e.g. video monitoring, telemedicine, wearables for vital sign monitoring) Minimise patient movement or transport Exclude visitors to patients with suspected or known COVID-19 Restrict unnecessary attendance at hospitals (e.g. medical students, members of public, research coordinators) Minimise or postpone elective admissions and operations Droplet and Contact PPE: Surgical mask, eye protection, disposable gown, gloves, and cap Droplet, Contact and Airborne PPE: N95 respirator (consider PAPR use), eye protection, disposable gown, gloves, and cap |
Aerosol-generating procedures | Perform aerosol-generating procedures only in presence of a clear clinical indication Consider alternative therapy (e.g. inhaled medications by metered dose inhaler and spacer rather than nebulised therapy) Consider conventional oxygen therapy (instead of NIV and HFNC) and early intubation for COVID-19 pneumonia Airborne precautions Issue hospital guidelines on aerosol-generating procedures Consider the use of PAPR if available and staff are trained in its use Procedure to be done in AIIR or single room Limit staff involved in aerosol-generating procedures Limit duration and exposure during aerosol-generating procedures (e.g. stop ventilation before circuit disconnection) |
ICU-specific measures | Consider high-efficiency particulate air (HEPA) filters at (Fig. 2) • Expiratory port of breathing circuit • Bag-valve-mask interface • NIV mask interface Use heat and moisture exchanger (HME) instead of a heated humidifier Use closed, in-line suction of tracheal tubes Measures to reduce dispersion of aerosols during intubation (Table 3) Use of single-use equipment (e.g. bronchoscopes) Segregate ICU equipment (e.g. ultrasound machines) Incorporation of infection control measures into ICU workflows (e.g. cardiac arrest and rapid response teams, transport, emergency operations and procedures) In situ simulation sessions |
Education and re-training
Segregation and surveillance
Maintaining manpower capability
SUPPLIES: equipping ICUs
STANDARDS: ensuring quality clinical care
Management of critical illness from COVID-19
Intubation and airway codes
Optimise patient safety | Infection prevention and control | |
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Preparation | Early identification of patients requiring intubation [35] Formulate airway plans A, B, C, D Don PPE with airborne precautions Prepare all equipment for intubation • Airway • Breathing devices, e.g. bag-valve-mask device • Breathing circuit | HEPA filter to reduce circuit and environmental contamination (Fig. 2a) |
Intubation | Preoxygenation for 5 min, with ‘head-up’ positioning when possible Consider PEEP valve with bag-valve-mask pre-oxygenation Consider nasal cannula (15 L/min) for apnoeic oxygenation Intubation by the most experienced operator Use video laryngoscope to optimise view through PAPR or goggles | Ensure good mask seal Avoid HFNC for pre-oxygenation Rapid sequence induction—minimise need for face mask ventilation [35] Small tidal volumes if ventilation unavoidable [35] Ensure full paralysis to reduce coughing [35] |
Post-intubation | Confirm tracheal tube position with capnography (difficult auscultation with hooded PAPR) | Positive pressure ventilation to be initiated only after cuff is inflated Sedation and paralysis to reduce coughing |
Transport of the intubated patient | Consider if transport is necessary Sedation and paralysis to reduce risk of coughing or inadvertent self extubation | HEPA filters for circuit and transport ventilator (Fig. 2) Place ventilators on standby mode and clamp tracheal tube for the period of disconnection [36] Adhere to a designated route with minimal contamination and exposure to other clinical areas |