ANZICS recommends the use of a risk assessment matrix (e.g. CDNA risk matrix Appendix 6) for any COVID-19 exposure. In more advanced phases of the pandemic with vaccinated staff it may be that revisions of the quarantine period (in conjunction with local jurisdictions) is necessary with regular testing to allow staff to return to work as appropriate.
We recognise there may be exceptional circumstances where quarantine periods for health care workers (HCWs) are adjusted with appropriate testing and infection control measures (e.g. organ retrieval, specialised procedures).
We recommend an efficient and operationally effective surveillance program for health care workers caring for COVID-19 patients to support workforce maintenance and safety.
We recommend ICUs maintain and update regularly a database (with standard confidentiality) of staff availability and other places or work. This should include categories i.e. general sick leave, COVID infection, COVID exposure/isolation, annual or other leave.
ANZICS recommends in order to facilitate and maintain a sustainable critical care workforce that additional recognition and support is considered which may include special leave or additional remuneration for medical, nursing, allied health and ancillary staff working in ICU.
ANZICS strongly supports the need for a long term sustainable nursing workforce. It is essential that nurse managers, nurse educators and staff development nurse positions are maintained and expanded to support nurses working clinically as well as educate and provide training to post-graduate student nurses.
We recommend that nursing staff capable of caring for critically ill patients be identified.
This includes:
We recommend a formal rapid orientation and training program is provided.
A database of who has completed the training program should be created at each ICU. These nurses should work under the supervision of an experienced ICU nurse.
We recommend that all current casual or part-time ICU nursing staff be encouraged to increase hours and that examination of roster patterns occur to maximise workforce availability whilst maintaining staff well-being.
We recommend that changes to models of care be explored, particularly models utilising team based care with increased ancillary and allied health staff to support ICU nurses (e.g. pharmacists assisting with checking and drawing up of medications).
We strongly recommend that changes to models of care for nursing only occur in advanced phases of the pandemic and that ICUs prioritise nursing staff welfare and patient care. Altered models of care with higher patient to nurse ratios are associated with increased mortality and should only be explored as a last resort in the black phase of the pandemic and only initiated at a state/jurisdictional level.
Wearing PPE for prolonged periods can increase fatigue and hence shorter shifts or more regular breaks should be considered. For periods where patients are stable and not receiving interventions, models of care may be altered to facilitate additional breaks. Local union participation is recommended as shift modifications may be impacted by relevant state nursing awards.
If a change in model of care is required, we recommend that an experienced ICU nurse should supervise a maximum of 4 up-skilled nurses, and not take on a patient load themselves, to ensure adequate patient safety and staff protection.
We recommend that nurses without critical care experience may be suitably trained and redeployed to assist with the following:
We recommend additional medical staffing for the ICU should be sourced by considering:
We recommend medical staff should be deployed in a manner that is aligned with their current scope of practice.
To ensure a sustainable workforce, we recommend the following:
Physiotherapy is beneficial in the respiratory and physical rehabilitation of patients with COVID-19 in ICU. Clinical practice recommendations for COVID-19 and minimum standards for ICU physiotherapists have been published. We recommend that physiotherapists with critical care experience be identified by hospitals and facilitated to return to ICU during periods of increased demand.
Patients with COVID-19 are at risk of developing post-ICU impairments, including ICU acquired weakness (ICU-AW). ICU-AW has independently been associated with increased morbidity and mortality.
The risks of COVID-19 transmission from physiotherapy interventions should be weighed against the benefits of the treatment being undertaken. We recommend the involvement of senior physiotherapists and medical staff in these decisions.
We recommend that physiotherapists provide extended support to the critical care team in the following areas:
The clinical responsibilities of ICU pharmacists include support of drug safety and prescribing, the reconciliation of patient admission medications and the procurement of important pharmaceuticals for patient management. These activities can be challenging during a pandemic, with the potential for medication shortages, changes to drug administration practices and rapidly evolving evidence.
We recommend that pharmacists with critical care experience be identified to manage any potential ICU pharmacy service shortfall (due to increased workplace demand or ill/quarantined staff).
The education, upskilling and support of these pharmacists is essential to assist the core ICU pharmacy service, with the aim of maintaining the recommended one pharmacist per ICU team/pod.
Social workers provide psychosocial care for patients and their support network during ICU admission. During periods of increased demand, we recommend social workers with critical care experience be made available to the intensive care unit with a focus on:
Dietitians provide expertise in nutrition management for critically ill patients, many of whom may have complex clinical conditions. The long-term impact of a prolonged ICU stay due to COVID-19 infection on nutritional adequacy is unknown.
During periods of increased demand, we recommend that critical care specialised dietitians look after the sickest patients, triage workload and provide clinical supervision to staff. Non critical care dietitians may need to be redeployed to ICU, under the supervision of an experienced clinician. This may include the use of nutrition assistants to support clinical dietitians.
Existing models of care may need to be extended to overcome food service delivery for patients in isolation.
Speech Pathologists provide expertise in the diagnosis, management and rehabilitation of swallowing functions, for ventilated and non-ventilated patients.
Patients may have diverse communication needs during a pandemic, particularly during periods of isolation and limited family visitation. We recommend that speech pathologists be engaged early to enhance and promote effective patient communication with staff and family. This may include augmentative and alternative communication systems.
The commencement of early rehabilitation may reduce the risk of protracted dysphagia and communication disorders. Specific techniques should be employed to minimise the risk of aerosol generation.