Planning for a COVID-19 Pandemic

It is essential that local and jurisdictional ICU pandemic plans be developed, resourced and implemented where appropriate by all healthcare organisations and that plans align with health department requirements. Pandemic plans should include operational approaches to reduce routine ICU demand, identify and increase physical ICU bed space capacity throughout the hospital, and determine equipment and workforce requirements.

It is essential that jurisdictions plan for sustained increased capacity rather than for defined periods of surge. There is clear evidence that mortality increases as a health system experiences ICU demand beyond usual capacity. Even in countries with high rates of vaccination, a consistent level of COVID-19 related ICU admissions persists, albeit with a large proportion from the unvaccinated population. ICU staff often work more in times of need, but this leads to fatigue and burnout and poorer outcomes for patients. The focus therefore needs to be on a sustained safe and effective workforce. We recommend collaboration between area health systems, load rebalancing and mobilisation of staff to assist in times of increased demand.

We recommend ICU operational status be monitored and reported in an expeditious manner to facilitate decision making processes, minimise system strain and maintain the standards of care required to achieve optimal patient outcomes. Effective information sharing to ensure delivery of the right information to the appropriate persons in a timely manner, is central to an effective pandemic response. We recommend ongoing support and funding for the Critical Health Resource Information System (CHRIS).

We recommend that ICU operational status be described in terms of both staffing and physical capacity, in recognition that a match between appropriate staffing and adequate infrastructure is central to the delivery of effective critical care services. This is demonstrated in Table 1 with a corresponding tiered, colour coded description of the current status.

We recommend that all efforts be made to ensure critically ill patients are cared for in ICUs with adequate staffing and physical resources with minimal compromise to usual models of care. A whole-of-health system approach involving both jurisdictional authorities and ICUs is absolutely necessary.

We recommend that ICUs do not enact individual surge plans or change models of care while there is still capacity in nearby areas. Partnerships, such as between private and public hospitals, adult and paediatric ICUs, and through telehealth arrangements to support different level ICUs, should be considered to ensure just and equitable delivery of care for all critically ill patients. This ensures the best clinical care and outcomes for critically ill patients.

We recommend that healthcare jurisdictions develop a phased response based on the impact of the pandemic on the operational status of the ICU. Demand for ICU capacity due to COVID-19 infection is likely to fluctuate across the duration of the pandemic and local authorities should develop triggers for escalation and de-escalation of their response. ICUs in Australia and New Zealand should aim to continue to operate with usual models of care (within the “green zone” in Table 1) as far and for as long as possible.

We strongly recommend that healthcare jurisdictions utilise periods of low case numbers to address staffing and infrastructure deficits for predicted future demand. It is likely that once vaccination targets are reached, government policies around border closures and lockdowns will be relaxed and a rise in cases will occur, albeit mitigated by vaccination.

Download Table 1 pdf

A whole-of-health system approach requires mechanisms to have a broad overarching view of current demand as well as projected demand. As a key determinant of capacity, and to improve access to ICU care for patients, visibility of immediate workforce availability is crucial.

We recommend the development of a framework to determine risk in order to support planning and the appropriate use of available resources. The components of this framework should include information on local prevalence, epidemiology of clusters, rate of new COVID-19 cases, variants of concern and the level of control measures in the community. Current Australian experience suggests that approximately 1% of identified community cases are admitted to ICU. Determination of risk can contribute to guidance on the use of PPE as well as the level of elective surgery performed.

We recommend establishing central coordination, involving senior clinicians, of ICU beds/capacity and transfers within each health system. It is recommended this be enacted whilst working within standard capacity to test the system, and identify and address any issues prior to more advanced phases of the pandemic.

We recommend regular meetings of ICU heads of departments (medical and nursing) within jurisdictions to address issues relating to significant differences in demand between ICUs. We recommend the use of local and national dashboards (e.g. the CHRIS dashboard) to help guide decision making.

The movement of patients between units may be required to ensure an equitable distribution of patient numbers and workload. The logistics of staff redeployment to areas of need should be explored early.

Communication within a pandemic is crucial to the successful delivery of safe and effective clinical services. The ever increasing volume of information and literature, research trial engagement and data, evolving guidelines, policies and procedures requires management and streamlining. Priority areas in information dissemination include daily situation reports at a local, regional and state level.

We recommend:

• Establishing effective lines of communication to ensure that stakeholders are informed of evolving clinical scenarios and changes in clinical practice guidelines and processes.
• Contributing data to the Critical Health Resource Information System (CHRIS). This is a bi-national dashboard providing real-time data on ICU bed, equipment and staff capacity across Australia and New Zealand. This knowledge assists in minimising delays in patients moving through care.
• The local development of tools for the timely measurement and dissemination of ICU load and capacity. These should facilitate decision making and support for the system-wide allocation of resources and the distribution of patient load.
• Ensuring adequate staffing to support timely data submission to ANZICS CORE and support of research activities, both COVID and non-COVID related. Data is essential to assist planning, review treatments and for the provision of excellent clinical care.

The following measures should be considered to reduce the overall as well as regionalised demand for critical care services and should be enacted before demand exceeds capacity.

Upstream Diversion

Regionalisation of outbreaks can create strain on some hospitals more than others. Subsequent transport of critically unwell patients between hospitals to address strain requires significant resources and time. With the understanding that patient transport and retrieval services have a limited capacity, ANZICS recommends exploring upstream diversion of patients before they present to the first hospital.

Streaming will require system-wide visibility of the ambulance network, ED, ward and ICU capacity.

Access to COVID-19 Testing

A substantial proportion of patients admitted to ICU will require testing for COVID-19 infection, particularly during periods of widespread community transmission, and subsequent clearance through polymerase chain reaction (PCR) testing. A delay in test results increases the demand on ICU resources, including staffing and the use of PPE.

ANZICS recommends the establishment of processes which prioritise and expedite the return of COVID-19 results for patients in ICU and other critical care areas (e.g. emergency department and operating theatres). All ICU patients for whom COVID testing is indicated should have rapid testing due to the resource implications and higher intensity of care required.

Deferment or Cancellation of Non-Urgent Elective Surgery

Deferment of elective surgery has significant public health implications and should be time limited. Exploration of all options should take place at early stages with the aim that elective surgery is supported throughout the pandemic. This includes load sharing within the public system and outsourcing to private facilities.

The decision to defer or cancel surgery will depend upon the impact of the pandemic on the operational status of the ICU. These decisions should involve ICU, surgery, anaesthesia and nursing services.

Interruption of elective surgery during amber and red phases will have significant public health implications but may still be necessary for short periods. The black phase will require cancellation of all elective surgical cases (including minor elective and day surgery). This will allow for staff redeployment, improved patient flow and conservation of PPE.

ICU Discharge Facilitation

We recommend implementing safe processes to expedite patient discharge from ICU during phases of increased demand. These may include additional support for ward staff to manage patients of higher acuity, or improving flow in discharging patients to areas with greater clinical oversight (e.g. neurosurgical HDUs).

We recommend that ICU specific protocols for the de-escalation of COVID-19 isolation measures be developed in consultation with infection control and infectious disease departments and with consideration of relevant guidelines e.g. the Communicable Disease Network Australia (CDNA).

These patients are likely to have prolonged stays and involvement with allied health and rehabilitation services. We recommend a multi-disciplinary handover process and establishment of goals of care for all ward transfers.

Reserving ICU Admission for Patients Requiring ICU-Specific Interventions

In more advanced stages of the pandemic (red and black phases), ICU admission should be prioritised for those who require specific ICU interventions such as mechanical ventilation and organ support. This may necessitate the following:

• Extended stays in the theatre recovery areas
• Admission to areas capable of HDU level monitoring (e.g. CCU)
• Additional support/supervision for ward staff to manage patients of higher acuity.

Proactive Consideration of Treatment Goals

We recommend early consideration of treatment goals to avoid ICU/HDU referrals or admissions in patients more appropriately managed on the ward. This may be facilitated by ensuring that all patients have documented goals-of-care or equivalent completed upon hospital admission.

ANZICS recommends patients are transferred to an ICU with capacity and appropriate infrastructure, rather
than remain in an ICU at capacity or with strained staffing and/or resources.

In addition, we recommend that all clinical areas with the physical infrastructure suitable to care for critically ill patients should be identified as part of hospital preparedness plans. These include (but are not limited to):

• Complex Care Units or other High Dependency Units
• Perioperative monitoring/recovery areas
• Coronary care units
• Uncommissioned or unstaffed ICU bays
• Decommissioned critical care areas (e.g. ‘old’ ICUs)

Criteria for high dependency area bed spaces (called ICU2 in some jurisdictions) are available via the College of Intensive Care Medicine guidelines.

We recommend hospital executive work with ICU clinicians to develop processes enabling the repurposing of these areas when needed and in establishing workforce models that allow for appropriate critical care staffing across multiple locations. The ability to meet the above standards may be limited in the advanced phases of a pandemic, necessitating adjustments based on the clinical needs of the patients and available resources.

Equipment

We recommend visibility of central supply stocks of equipment (at state level) as well as transparent plans
for distribution to allow feedback and planning for increased demand.

We recommend ICUs should quantify current stocks of equipment (e.g. ventilators, renal replacement
therapy, infusion pumps) including consumables and disposables as well as assess potential requirements
with increasing ICU load. ICUs should also identify available channels for the supply, storage, and procurement of additional equipment.

This may include:

• Equipment from operating theatres / perioperative environments
• Older but functional equipment not presently in use (e.g. old ventilators which can be operationalised by biomedical departments)
• Manufacturers and suppliers
• Hospital, state or national emergency stockpiles
• Jurisdictional procurement agencies

Download Table 2 pdf

It is likely that staff shortages and in particular critical care nursing, will be the greatest limiting factor on ICU capacity when there is widespread community transmission of COVID-19 infection. The high chance of staff furlough and potential healthcare worker infections means a significant proportion of ICU staff may be absent from the workplace during advanced stages of the pandemic. The COVID-19 pandemic has also resulted in limited immigration which has had a significant impact on critical care medical and nurse staffing across Australia and New Zealand.

Due to these potential workforce shortages, non-critical care trained medical, nursing and allied health staff may have to assist in the care of ICU patients. This should occur with the relevant managerial authorisations, and under the supervision of critical care trained staff, utilising a team-based model of care.

ICUs and hospitals should prioritise meeting the minimum standards for staffing as per the College of Intensive Care Medicine and the Australian and New Zealand Colleges of Critical Care Nursing guidelines. However, available resources may change depending on the demand placed upon a health service.

We recommend workforce planning should include consideration for pandemic specific requirements, such as additional workload from donning and doffing of PPE, the need for additional rest days, and the need to allocate staff to key non-clinical duties such as enforcing infection control procedures. Healthcare jurisdictions must also account for staff furlough, which is likely to occur with staff exposure in the setting of community transmission.

We recommend the use of all available resources to optimise workforce capacity, by identifying and potentially redeploying nursing, medical, allied health and other staff.

We recommend that core ICU staff maintain operational readiness through ongoing education, simulation and revision of COVID-19 protocols during periods of low community viral transmission. We recommend that where staff are requested to perform duties outside their usual scope of practice due to severe workforce shortages (e.g. anaesthetists taking on an intensivist role), this should be at their discretion, with adequate supervision and orientation and with jurisdictional reassurance regarding indemnity coverage.

We recommend data collection and research be considered essential services to help guide future directions through the pandemic. These activities must be supported and if needed, alternatives explored to ensure they continue.

We recognise the importance of training and supporting healthcare students throughout the pandemic for a future sustainable workforce. During advanced phases of the pandemic, significant strains on staffing may not allow traditional student teaching.

We recommend exploring other options such as utilising students for appropriate roles in team-based models of care.

If students are undertaking such roles, then we recommend that they should be paid for such roles and consideration be given to having an agreement with the health service to ensure they are provided with appropriate indemnity cover, liability insurance and Workcover protection.

Additional Workforce and Staffing Considerations and Recommendations

Many patients who survive an episode of critical illness go on to develop more chronic impairments of physical, cognitive and psychological health, recognised collectively as Post-Intensive Care Syndrome (PICS). Family members may also experience mental health impacts recognised as Post-Intensive Care-Family (PICS-F).

Data suggests a proportion of COVID-19 sufferers develop long-term health impairments, referred to as “long COVID-19”. Risk factors for the development of prolonged health impairments include pre-existing frailty and functional impairment, a prolonged ICU stay, delirium and sepsis. Following discharge from ICU, depression, anxiety and the development of post-traumatic stress disorder increase the risk of long-term impairments.

In Australia, many of those who were critically ill with COVID-19 have reported new problems with physical, cognitive and psychological function at 6 months after the acute illness, similar to the experiences reported internationally (Table 3).

Download Table 3 pdf

Prior to and/or following hospital discharge, ANZICS recommends that:

• Survivors of critical illness be screened for new disability using standardised assessment of physical, psychological and cognitive function (Table 4)
• Patients should be re-screened through their GP or ICU follow-up clinic at 12 weeks post-COVID-19 symptom onset and to monitor for ongoing symptoms and problems
• Survivors with ongoing symptoms or disability should be referred to appropriate services with a multidisciplinary plan in place
• Peer support be arranged (including through virtual platforms) for patients with ongoing symptoms and their caregivers
• Guidance be provided to patients and caregivers regarding their anticipated trajectory of recovery
• Patients are educated about medications, equipment, rehabilitation requirements and advice about emergency assistance if they deteriorate (see resources in Appendix).

Download Table 4 pdf

Due to the highly transmissible nature of this disease, strict ICU visitation controls are necessary. It is recognised that this can contribute to complicated grief for members of the public and moral distress for healthcare workers. Therefore, ANZICS endorses the position statement on facilitating next-of-kin visitation, jointly endorsed by the Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control.

Family visitation may be considered appropriate in certain circumstances (e.g. during end-of-life care). Visitor safety is paramount; hence family visitation should be in alignment with jurisdictional recommendations, and where local resources and staffing permit.

Family visitation should be limited to the next-of-kin or immediate family, who must be deemed fit and well, not self-isolating due to COVID-19 exposure, and not currently COVID-19 positive.

A member of the ICU team should take responsibility for informing visitors about how the visit will be conducted, pre and post-visit hygiene requirements, use of PPE, anticipated timing and duration, and provide instructions for the bedside visit. On arrival, family visitors should be assisted to don PPE and escorted to the bedside. Where possible, the family/ visitors should be provided with time alone with the dying person. At the end of the visit, an ICU staff member should assist the family visitor to doff all PPE and exit. Where warranted, immediate emotional support should be provided, and details of additional support services such as pastoral care or bereavement support services provided.

We recommend:

• A communication plan is established with families shortly after ICU arrival, offering different communication platforms and identifying and mitigating any potential barriers to communication and engagement • ICUs explore and implement methods of communication that allow for patient and clinician interaction with family members, and establish appropriate governance and best-practice guidelines
• Families, where possible, allocate one family member as the key contact, who will take responsibility for disseminating information amongst the greater family unit
• ICUs allocate one person or a team to provide daily updates for each patient to the nominated family member
• Equipment/technology with secure platforms be made available for video conferencing between patient, family and medical staff. This includes a means for communication with relatives who may be overseas or interstate. Units should liaise early with information technology departments as multiple devices with Wi-Fi capability may be needed
• Families are encouraged to maintain contact with patients through other means, such as web-based remote family conferences, diaries, drawings and text messages
• Consideration be given to how the explanation of restrictive visitation policies is delivered (standardised communication, leaflet, public-facing website)
• Mechanisms exist for the delivery of essential items to the patient such as glasses, dentures, phone chargers etc.

ANZICS recognises that patients in remote, rural and regional areas are at additional risk of health disadvantage in a pandemic. We advocate for geographical equity through the maintenance of usual standards of care for all patients. This includes the availability of sufficient resources such as equipment and workforce, ongoing access to clinical trials, contributions towards jurisdictional databases (e.g. CHRIS, ANZICS APD/ANZPICR) and timely support for patient management.

ANZICS recognises that remote communities are at increased risk and supports jurisdictional decisions to protect these communities through public health measures until appropriate vaccination targets are met.

ANZICS strongly supports the recommendations in the Australasian College for Emergency Medicine’s COVID-19 Toolkit for Rural Emergency Care Facilities in Australasia. This document contains an audit tool for remote, rural and regional health services to assess their critical care capacity and ability to provide ventilatory support.

Workforce

The most likely rate-limiting factor in supporting remote, rural and regional critically ill patients during the pandemic is critical care qualified nurses. There will also be shortages of medical and allied health staff. Health services with staffing models relying on fractional appointments, fly-in-fly-out (FIFO), locum and/or agency staff are at particular risk.

Mobilisation of staff to non-metropolitan areas has additional logistical challenges related to geography (e.g. accommodation and transport) that require consideration. The ability to utilise team based rostering to mitigate the risk of staff cross-contamination and reduce the impact of staff furlough is logistically more challenging in rural and regional settings.

We recommend:

• Anticipating workforce shortages/challenges early and addressing these in a proactive manner
• Identifying local nursing staff and other local health care workers for a critical care upskilling program
• Establishing and/or formalising links with metropolitan or larger regional units to facilitate critical care upskilling
• Exploring on-call provision from alternative sites to support local intensivists who may have a greater on-call burden
• Identifying, facilitating and providing practical support for locum doctors and agency nurses who wish to remain at a regional/rural health centre for a longer period.

We advocate for a centralised process to mobilise critical care trained staff to areas of need during local outbreaks of the pandemic. This may include periods where large numbers of healthcare staff are furloughed.

Capability and Capacity

In facilitating the care of critically ill patients in remote, rural and regional health services, We recommend:

• An emphasis on early, proactive community and hospital-based goals of care discussions, as these may influence decisions to treat locally or seek retrieval.

We recommend consideration of regional hubs to centralise staff and resources. The capability of the hub needs to be defined, measured and resourced with appropriate metrics. The hubs should aim to care for lower acuity patients with clear triggers for transfer to metropolitan centres.

In planning to expand health service capacity, we recommend:

• Hospitals nominate a COVID-19 critical care leadership group with delegated authority for pandemic planning and management
• Resident intensivists in regional ICUs allocate time to proactively assist local acute wards and smaller hospitals in their planning and training for pandemic critical care
• Hospitals take a regular inventory of ventilators, ICU equipment, medications, PPE, available clinical areas, and diagnostic services (including COVID-19 testing).

In the event that health services are expected to manage ventilated patients beyond existing capacity, we recommend:

• Identification of staff (medical and nursing) with critical care and airway skills to provide 24/7 cover of ventilated patients.

In health services unable to provide invasive ventilation, we recommend:

• Plans are made to facilitate early retrieval
• Consideration be made towards what respiratory support is feasible. This may include the provision of HFNO and NIV with appropriate support and caution.

Education

In order to maintain a workforce with the necessary knowledge and skills and to ensure that staff stay informed of changes in COVID-19 management, we recommend:

• Use of the National COVID-19 Clinical Evidence Task Force Guidelines and appointing medical and nursing leads to keep staff informed of changes
• Accessing educational resources through local and remote platforms (e.g. by video link to educational sessions in regional and metropolitan hospitals).

Telehealth

ANZICS recommends expanding the use of telehealth and virtual care services to provide additional advice and support to health care staff in facilitating improved local care and patient transfer considerations.

ANZICS recommends a central telehealth service or that metropolitan and larger regional units take responsibility to provide telehealth support to smaller regional units. Daily virtual ward rounds in advanced stages of the pandemic should be considered.

Staff Support

Fear and anxiety during the pandemic may be more pronounced for remote, rural and regional staff for multiple reasons including the increased risk of treating friends, family or colleagues, heightened resource restrictions and challenging clinical conditions.

ANZICS recognises that psychological support can be more challenging in rural and regional areas. We advocate for equity of access to resources that support staff wellbeing and psychological stress mitigation.

When compared with adults, COVID-19 infection is an uncommon cause of severe or critical illness in children. Most children with COVID-19 are asymptomatic or have only mild respiratory signs, but between 2 and 20% of hospitalised children with COVID-19 infection may need ICU admission. This is based mainly on data from childhood infection with the Alpha variant.

Children under 12 years will remain a vulnerable cohort if they are not included in the vaccination programme. There has not been modelling of the impact on paediatric critical illness and PICU admission of the Delta strain as a single infectious agent or as co-infection with Respiratory Syncytial Virus (RSV) or other respiratory viruses.

Children with chronic underlying diseases are susceptible to serious complications of COVID-19 infection. Paediatric patients with cerebral palsy, chronic lung disease, congenital heart disease, type 1 diabetes, immune problems and cancer, are more likely to be hospitalised and are at higher risk of dying than the general paediatric population. Adolescents with obesity or hypertension are also at an increased risk of complications.

Clinical manifestations of COVID-19 infection in children may differ from adults. In addition to the more commonly seen manifestations such as pneumonitis, COVID-19 infection may lead to a generalised viral illness, with high fever (T>39 C), erythematous rash, diarrhoea and vomiting.

Rarely, COVID-19 in children is associated with a delayed hyper-inflammatory syndrome called Paediatric Inflammatory Multisystem Syndrome – temporally associated with SARS-CoV-2 (PIMS-TS). This can appear similar to Kawasaki disease and toxic shock syndrome and may be fatal. PIMS-TS may occur during an acute COVID-19 pneumonitis or more commonly 2-4 weeks afterwards when evidence of COVID infection may only be manifest by detection of COVID antibody.

We recommend that the identification and management of COVID-19 infection in paediatric patients is in accordance with the National COVID-19 Clinical Evidence Taskforce https://covid19evidence.net.au/.

We recommend:

• The same principles of infection control and staff safety as for adult ICU patients (see ANZICS guideline Section 2: Staff Safety)
• Strategies are implemented to avoid impacting the ongoing intensive care management of paediatric patients.
• The developmental and psychosocial needs of children are considered when infection control measures are instituted.
• There is a low threshold for the testing of paediatric patients and parents/carers on ICU admission to ensure early clearance from COVID-19 precautions and greater certainty on measures to mitigate risk of inadvertent cross infection of vulnerable patients and families. In periods of high community transmission it may be appropriate to test all paediatric ICU patients and essential visitors on admission.
• Visitors are restricted to one or two family members during periods of significant community transmission (see ANZICS guideline Pandemic Planning: Family Engagement). This should be based on an assessment of COVID-19 infection risk and may involve surveillance swabs of visiting family members, with specific measures to manage the needs of children with COVID-19 positive parents or carers.

Physical distancing and mask wearing reduces the incidence of unplanned paediatric ICU admissions with seasonal respiratory illness. Additionally, the deferment of non-urgent elective surgery during periods of widespread COVID-19 transmission may increase PICU bed capacity.

It is possible that PICU clinicians may need to be redeployed to manage adult patients during periods of increased demand. We recommend that any staff redeployment be supported with appropriate training and education. This should only occur if there are sufficient resources within the PICU workforce to manage essential services (e.g. paediatric trauma, burns, organ transplant and urgent surgery) in addition to the emergency admission of COVID-19 and non-COVID-19 infants and children. It should take place as part of a system-wide plan to manage an overwhelming case load in adult facilities.

The principles of critical care outreach should have pre-emptive, proactive and reactive solutions to:
1. Identify patients who are unlikely to benefit from ICU treatment and guide appropriate goals of care discussions
2. Identify patients who need ICU as early as possible by:
     a. Pre-emptive rounding and huddles between ward-based and ICU-staff
     b. Modification of RRT calling criteria
3. Prevent In-Hospital Cardiac Arrest (IHCA) in COVID positive patients, as this is associated with an inhospital mortality > 90%.

Where possible, there should be a senior decision maker (senior registrar or consultant) from ICU available to assist in these processes.

ANZICS supports the recommendations of the International Society for Rapid Response Systems (iSRRS). Modifications to rapid response team (RRT) models of care should align with these guidelines whilst being individualised to the needs and resources of each jurisdiction.

In order to minimise the risk of healthcare staff infection, we recommend that:

• Health services review Rapid Response Team models of care for ward patients with COVID-19 infection, with consideration given towards the need for enhanced infection control measures
• All RRT members receive training in donning and doffing of PPE, and that PPE for airborne precautions is readily available to RRT members for patient interactions
• During a MET call or code blue, entry to a patient’s room should be limited to vital members of staff
• A therapeutic escalation plan be developed for patients with COVID-19, with particular consideration to appropriate infection control measures for aerosol- generating procedures
• Consider inclusion of notification of potentially infectious COVID status in the pathway for RRT activation (via PA announcement or paging tree)
• Where possible, wards should identify appropriate locations for delivery of high-flow nasal oxygen, noninvasive ventilation, and endotracheal intubation
• If aerosol-generating procedures (AGP) are required, these should ideally be performed in a negative pressure room, however, this needs to be balanced with the safety of transporting the patient.

In order to reduce the demands on ICU staff and facilitate optimal patient management and disposition, we recommend that:

• All patients have their goals of care clarified on hospital admission, and that this be communicated clearly to the RRT members on arrival
• Hospitals should increase the ICU workforce to ensure sustainable rostering of staff to critical care outreach services
• If staffing permits, the ICU will maintain a senior decision-maker for the assessment of patients outside the ICU. This may also include the use of virtual ward rounds or huddles to limit traffic through COVID wards
• Alternative non-ICU based MET team staffing models should be considered as part of advanced phases of the pandemic response. These models may involve RRT staffing by non-ICU staff, but must include appropriate training of members
• Clinical criteria for RRT activation in COVID-19 patients should pay particular attention to escalating oxygen requirements (FiO2), respiratory rate and work of breathing, which have been associated with adverse outcomes. These criteria may need to be altered depending on the stage of the pandemic, caseload and emerging evidence for treatment
• Hospitals identify COVID-19 patients at risk of clinical deterioration and develop a strategy for information sharing with critical care services. This will enhance the clinical visibility of the ward burden of COVID-19 patients and anticipated admissions to ICU. This may also include unique RRT alerts for COVID-19 patients to enhance staff preparedness.

In principle, the movement of patients with COVID-19 should be limited with all efforts made to ensure the patient is initially admitted to the appropriate location and only necessary investigations are performed outside the ICU. Staff safety is paramount and all staff involved in transferring a patient with suspected or proven COVID-19 infection must be proficient in the use of PPE and infection control procedures.

Intra-hospital Transport

Once a patient is admitted to the ICU, transport outside of the ICU should be limited. If transport is required, then coordination at a senior level is mandatory to ensure safety standards are maintained.

We recommend the following for intra-hospital patient transport:

• All staff undertake airborne precautions with appropriate PPE at all times
• Intubated patients should have closed ventilator circuits with a viral filter in situ
• Hallways must be cleared and only essential staff should accompany the patient. This should be planned ahead of time where possible to avoid any breaches. Staff not involved in the transfer should not come within 2 metres of the patient. The shortest and safest transport route should be identified.
• A designated staff member in PPE, maintaining a 2 metre distance from the patient is needed to open doors, access lifts and ensure infection control precautions
• Clear agreeme nt on which speciality/team will be responsible for the intrahospital transport of critically ill patients from ED to ICU
• ED staff involved in any prolonged or resuscitative care should ideally not transfer the patient or don fresh PPE to do so.

Inter-hospital Transport

Capacity for inter-hospital transport is likely to be limited and may significantly impact access to critical care for regional Australian and New Zealand patients. Redistribution of patients as part of a load rebalancing strategy to address health areas under strain will involve patient transport services (both aeromedical and
road). We strongly support efforts to increase the capacity of these services.

A balance needs to be made between having patients treated at a centre with greater resources and overwhelming patient transport services with high numbers of low acuity transfers. Transferring patients later in their clinical course may necessitate intubation for patient and staff safety or logistical reasons as higher levels of oxygen flows via mask or nasal prongs may exhaust oxygen supplies.

We recommend a means of central coordination for inter-hospital transfers utilising senior clinicians in later stages of the pandemic (red and black). This should leverage off existing governance structures and incorporate clear lines of communication, balancing individual clinical need, against local and system-wide resources. This will allow treating clinicians to focus on clinical care.

We recommend:

• That transfer capacity be explored locally (e.g. using local anaesthetists and ambulances) in addition to existing retrieval services
• Accessibility to teleconference technology to allow face-to-face discussions between senior clinicians to discuss cases and provide support and advice
• Clear agreements on accepting facilities be in place prior to transport
• The development of local guidelines or triggers outlining clinical criteria (e.g. FiO2, respiratory rate) where transfer for care escalation is mandated
• That early transfer be considered for sites unable to provide short term ventilatory support to avoid the need for intubation
• That rapid and accurate COVID-19 point-of-care testing be used. This will assist with clinical management and help determine whether co-transfer of more than one patient is possible
• That retrieval services call ahead when a clear arrival time is known so that patients can be escorted directly to ICU by dedicated staff in appropriate PPE
• That retrieval services examine their ability to provide NIV or HFNO and if safety concerns are present for staff or patients, then patients are intubated prior to transfer. Patients receiving oxygen should where possible have a surgical mask placed over their oxygen device
• That PPE decisions are based on clinical and epidemiological risk factors with reference to the CDNA or jurisdictional PPE matrix
• Retrieval/transport crews be provided a safe area to doff their PPE and decontaminate prior to returning to their point of origin. Crews cannot eat or drink whilst wearing PPE and so should be given access to refreshments.

Facilitating Emergency Department (ED) Management

ANZICS recommends that ICUs co-ordinate with EDs to support the management and disposition ofcritically ill patients during periods of high COVID-19 patient load.

Inter-departmental plans should include the early referral to ICU of patients (both COVID-19 and non-COVID-19) requiring physiological support as a means to optimise patient flow and improve emergency department capacity.

We support the Australian College of Emergency Medicine COVID-19 guidelines and recommend they be considered in the development of local policies.

Metrics and data monitoring are central to the provision of a safe and high-quality healthcare system. They are an essential component of the NSQHS Clinical Governance Standard (Standard 1 Action 1.08 and 1.09), which aims to ensure the implementation of a framework within health service organisations that maintains and improves the safety and quality of health care.

General Principles

We recommend that metrics and data monitoring take place within the framework of a programme with clear and achievable goals and practical steps for implementation. Metrics in themselves, outside of a plan of action, are without meaningful value. The principles of data security and structured governance processes around the collection, storage and reporting of data are the same during the pandemic as they are at other times.

ANZICS recognises that the collection of relevant and accurate data is required to provide visibility of activity and resources of a health care system and the intensive care services within that health system. The secondary purpose of this data is to provide a basis for health policy development, future health service and intensive care planning and research.

We recommend that:

• Data should be accurate and consistent, collected and submitted at regular intervals to provide both real-time information and longitudinal data
• The frequency of data assessment reflects the needs and goals of the program Operational information often requires near real-time availability of data. In contrast, outcome/performance monitoring and clinical trials typically involve measurement and reporting of information over longer periods of time
• Metrics be easily obtained and recognised as useful by all stakeholders and serve to advance scientific progress or inquiry
• Metrics evolve to keep pace with scientific progress and be regularly reviewed to ensure relevance
• The standard principles of data collection are adhered to, including the security, storage and use of data. Data collection should occur within existing approvals
• Pre-existing principles such as ‘The Five Safes Framework’ promoted by the Australian Institute of Health and Welfare, be applied to the reporting and sharing of information resulting from these data.

The development and application of meaningful metrics will require human, financial and computational resources. ANZICS recommends that data collection systems should be integrated into the health care system and have longevity. We recommend that data collection should be performed and overseen by dedicated staff who are funded and trained specifically for this role. We recommend delivery of care to all critically ill patients is monitored and a well-established reporting system is in place, so that analysed data can be interpreted and findings can be actioned by relevant bodies/authorities.

Additional Considerations and Recommendations