Covid-19 : Paediatric Intensive Care Unit Contingency Plan

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The requirement to increase critical care capacity, and to initiate other changes in critical care practices/organisation, will vary according to the type and severity of the incident. These will be activated in a stepwise fashion in response to clinical pressure.

At present the Paediatric Critical Care Department is commissioned to provide 17 intensive care beds and has 22 physical bed-spaces. There is capacity to expand PICU into Ward 1E thus providing another 14 beds. This will bring PICU bed capacity from 17 to 36 beds.  In addition the Neonatal Unit has 50 equipped intensive care beds.

 

There are currently NHS Planning prompts available for each speciality. The NHS Critical Care Plan and WHO Clinical Guidelines can be found here:-

European Centre for Disease Control Planning Guide:-

WHO Covid-19 Clinical Guideline:-

Resuscitation Guidelines can be found here:-

Staged Expansion of PICU Services Plan

Acute Stage 1

Pandemic Covid-19 imminent and likely to affect NHS GGC

During this phase elective PICU activity and non-essential neonatal activity will be reduced to allow time for staff training:

  • Low urgency & elective procedures should be cancelled to facilitate staff training and reorganisation
  • ICU + neonatal staff (all sites) should be trained in use of PPE
  • Ensure list of staff with PICU skills maintained and updated e.g. recently retired or redeployed medical and nursing staff who have moved to theatres / cath lab / community etc.
  • Theatres, recovery, community midwife and other staff who may be able to work within the PICU/ NICU should receive brief introductory training
  • Planning for cancellation of study leave and management of annual leave
  • Suspension of research activity on ward
  • Planning for suspension of educational meetings
  • Arrange upscaling of Metavision to cover whole of Ward 1E
  • Liaise with Labs / IT / Estates regarding movement of Point of Care tests / Blood gas analysers for infected and non-infected patients. Dedicated contacts within these departments must be established early.

Acute Stage 2

Pandemic Covid-19 affecting  NHSGGC; small increase in ICU demand

  • Cancellation of all routine elective surgical procedures requiring an ICU bed
  • Caution accepting referrals from outside GGC (consider PICU pressures) – ensure Covid-19 status known prior to accepting referral
  • Cohorting to protect uninfected patients
  • Anaesthetic staff available from elective activity would be seconded to PICU
  • Staff with transferable skills and update training re-deployed to ICU/ NICU
  • Existing nurse patient ratios and standards of care would generally be maintained
  • Caution would be exercised in the use of very high intensity support eg ECMO: continued provision for patients with good prognosis especially where likely to shorten intensive care duration eg neonatal ECMO for MAS

Acute Stage 3

Pandemic Covid-19 affecting  NHSGGC; moderate increase in ICU demand

  • Expansion of PICU into Ward 1E
  • Cancellation of all non emergency surgery
  • Triage access to PICU and all NICU sites – restrict access for patients with poor long term prognosis
  • Use theatre recovery area to ventilate post operative & other ‘clean’ patients
  • Staff ratios will be compromised & staff with no ICU training will be required to assist.  A register of staff with ICU skills will be maintained by lead nurses.
  • Patients may require periods of ventilation in non ICU areas eg wards & A&E while awaiting admission to ICU – medical but not nursing support may be available
  • Patients who can be supported using acute non invasive ventilation may be admitted to designated non-ICU ward
  • High intensity therapies eg haemofiltration would be strictly triaged: provision of ECMO may become unsupportable
  • Parents will be required to contribute to routine care tasks
  • Normal professional standards and practices may have to be abandoned in order to manage patients eg increased use of physical restraint

Acute Stage 4

Pandemic Covid-19 affecting NHS GGC; further increase in ICU demand

 

As intensive care capacity in terms of equipment, supplies or personnel becomes exhausted it will be necessary to accept substantial compromises in the quality of, and access to, intensive care compared with established practice. This situation would impact across paediatric and neonatal critical care services.

  • Staff ratios will be markedly compromised
  • Much care will be delivered by inadequately trained and supervised personnel or parents
  • Strict triage decisions for access to both paediatric and neonatal critical care services must be made based on expected long term outcomes and expected quality of life
  • High intensity therapies eg haemofiltration will not be possible
  • Substantial use may be made of improvised equipment or re-used single use items
  • Disposable equipment and CSSD supplies may fail requiring improvised solutions
  • Emergency respiratory support as part of resuscitation will not be provided when no intensive care capacity is available

Acute Stage 5

Pandemic Covid-19 affecting NHS GGC; ICU demand outstripping availability

This would be a catastrophic event with a high proportion of the population (including staff) severely affected.

  • ICU capacity may be reduced to allow staff to be re-deployed
  • ICU space may be re-allocated to general care
  • Strict triage decisions would select ‘best outcome’ or short duration patients for any remaining capacity – may be restricted to patients who do not have Covid-19 or neonates who require SCBU level care.

Important notes

  • The total number of beds in operation at any one time will depend on availability of staff, equipment & supplies.
  • There will be a need for additional staff as “runners” and for additional support staff e.g. clerical staff
  • The number of spare ICU ventilators across GG&C is limited and ventilation with an anaesthetic machine ventilator is not optimal.
  • Indemnity for all staff working in these adverse conditions must be assured
  • Good staff communication and support are paramount to the success of escalated ICU capacity
  • Adequate supplies of PPE and education regarding their use and infection control procedures are vital
  • In event of overwhelmed PICU services adult ICUs may need to accept paediatric patients. Trigger points have been identified for the various points where the adult ICUs will support Paediatric ICUs according to clinical condition.
  • A central bed bureau will aid co-ordination of available beds
Critical Care Reserve Workforce Expansion Plan

Neonatal and Critical Care services will identify staff groups with transferable skills who can be used to supplement staff numbers.

Within neonatal services community and other midwifery staff will be identified to supplement SCBU care to release NICU staff to focus on intensive care provision.

Within PICU supplementary staff will be trained to assist ICU to perform care tasks for ventilated children. Theatre staff released from elective work will be the principle target group. Other specialist nurses with a background in ICU will be encouraged to be available.

A 1/2 day ‘crash course’ has been developed to orientate supplementary staff and provide an introduction to basic ICU procedures.

In order to minimise staff absence due to reluctance to work in intensive care areas, good education and training in infection control and use of personal protective equipment (PPE) is essential.

As the pandemic escalates currently accepted levels of expertise and nurse-to-patient ratios are likely to be compromised. A hierarchy of skills will be evident:

  1. permanent critical care staff
  2. staff who have undertaken a brief PICU training course & orientation
  3. other qualified staff
  4. unqualified staff

Ad hoc training and orientation for staff at different levels may need to be delivered depending on the level of service being provided and the availability of trained staff.

Reserve medical workforce

With the cancellation of elective work anaesthetic staff with ICU experience will be able to provide additional medical support for care of critically ill ventilated patients. Other clinicians with relevant skills may also be able to contribute but it is unclear whether this will augment capacity or improve care in PICU. Supplementary medical staff may be most usefully deployed managing seriously ill patients elsewhere in the hospital.

Basic principles of staffcare
  1. Minimise staff exposure at all times as a priority
  • PPE must be worn according to HPS / GG&C Infection Control Guidance - https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control
  • PICU counts as a high risk of transmission area – PPE must be worn when in Covid-19 patient areas
  • PPE required for stock as below – taken from ECDC advice
  • Minimise staff entering Covid area
  • Minimise blood sampling, blood gases and radiology investigation to those deemed essential to minimise staff transmission risks
  • Staff at risk of severe complications must not look after Covid-19 patients
  1. Facilitate staff return to work
  • A priority list of asymptomatic staff who are self-isolating due to symptomatic household contacts should be made. There is a system via Public Health Protection Unit (PHPU) to enable testing of symptomatic family members to facilitate rapid return to work. 
  • This list should be escalated via service managers.

    It is essential that medical staff absence is accurately reported and recorded, particularly at the present time. Individual staff members should:-

    Notify their line manager of their absence
    Email the following information to  Covid.absencereporting@ggc.scot.nhs.uk
    Name
    Department
    Grade
    Reason for absence
    Self isolation due to own symptoms
    Self isolation to due high risk category (please specify)
    Self isolation due to
            symptomatic family member,
            Covid 19 positive,
            Other
            Date of onset of above
             Anticipated date of return
COVID 19 PICU Practical Bed Escalation Plan – as of 20th March 2020
  • Bed planning hierarchy – option to expand to 36 PICU Beds
  • SCOTSTAR Referrals – aim to stay in referring centre until virology available if possible
  • Early viral testing essential for safe patient flow
  • Plan must remain flexible depending on patient and staffing pressures

Basic Plan

  • Initial aim to keep Covid patients in Pod 1, allowing Pod 2 and Bed Bay 8-11 for non-Covid 19 PICU (Bed 8-11 blocked off from Pod 1 and accessed via side door only)

  • Covid 19 patients to take over entire Pod 1, including Bed Bay 8-11. Non-Covid 19 patients in Pod 2 only

  • In event of further escalation
    • Covid 19 patients remain in PICU Pods 1 & 2 (22 beds) – “Covid 19 PICU”
    • Non-Covid 19 patients move to Ward 1E (14 beds) – “non-Covid 19 PICU”

  • Minimise non-critical PICU patients: -
    • Non-Covid LTV / High flow / Mask BiPAP (own machine) / Bubble CPAP patients to Ward 3C (“clean”, non-Covid patients only)
    • Appropriate non-Covid smaller patients to NICU – e.g. CLD, Coarctation, PA Band, General Surgery. Neurosurgery (VP shunts etc) - this will likely require back transfer of NICU patients to RAH, PRMH, DHG NICUs etc.

  • Option to expand to Theatre Recovery if more beds required
Bed-Specific Plan Hierarchy
  • Please follow bed allocation in order set out as below
  • Adaptations may be required depending on nursing staffing numbers
  • Cubicles and Cohort areas will require Computer-on-wheels / Laptops placed outside to allow access to patient record +/- remote prescribing
  1. Cubicle 5 – negative pressure with antechamber. Confirmed or suspected case.
  2. Cubicle 12 – PPVL with antechamber – HEPA-filtered. Patient Room is not positive pressurised. Lobby is positive pressure but exhausts via dedicated 3m chimney. Does not exhaust into ward.
  3. Cohort area – Beds 1-4: use screened off area outside 4-bed bay as donning / doffing area
    1. After doffing use sterilium then proceed to Cubicle 6 to wash hands
    2. in event of cohorting aim to leave Cubicle 5 empty if possible as testing area for non-confirmed suspected emergency admissions.
  4. Cubicles 7 – non-pressurised, no antechamber.
  5. Cubicle 6 to be left as donning and doffing area for cubicle 7 and cohort areas
  6. Bed bay 8-11 should be blocked off so no entry via Pod 1. Exit via side door to allow non-Covid patients to be looked after in this Bed bay. Side door must be kept closed when not in use.
  7. Covid Cohort area expanded to include all of Pod 1, including Beds 8-11. Donning/Doffing area set up outside 4 bed bay in Pod 1 corridor (outside Cubicle 12 – must be screened off from Cubicle 12 to allow exit). Use sterilium after doffing before proceeding to Cubicle 6 to wash hands.
  8. Expansion of Covid 19 patients into Pod 2 and re-location of non-Covid patients to Ward 1E

 

Management of suspected cases

Essential Equipment - Ventilators

Current situation:- We have 29 mechanical Ventilators in PICU. This includes:-

  • 14 Evita XL
  • 9 Servo i
  • 5 HFOV Sensor Medics – these do not currently (12/3/20) have viral filters in exhaust gas outlet so should not be used until filtered circuits made available. Circuits with filters being ordered.
  • 1 Hamilton Portable Vent

As of 20/03/20 14 further PICU-specific mechanical ventilators were on order but are not immediately available.

Other sources of ventilators:-  see below

  1. Theatres
  2. NICU
  3. LTV team

Cuffed ETT is recommended

HME, water-free circuits should be considered.

NICU has 12 Fabian ventilators – used in neonates but can potentially ventilate up to 30kg.

In total there are 55 ventilators between NICU / PICU and ED – although this includes some ventilators that are designed for small infants only e.g. 2 x babypacs.

Ventilators must have exhaust filters fitted.

Extra ventilators may be sourced via Medical Physics / Procurement – discuss early.

LTV/Respiratory Team

In event of overwhelming demand the Long Term Ventilation Team has access to ventilators – these are not designed for PICU but could be accessed in the event of a crisis:- as of 20/03/20

Ready for use

4 Stellars

7 VPAP3

5 Astrals

Awaiting repair

2 Stellars

1 VPAP3

RHC Theatres

Non-invasive ventilation / NCPAP / Hi-Flow O2 in proven or suspected Covid-19
  • A risk assessment should be undertaken before use.
  • Hi-Flow O2 and Non-invasive ventilation are continuously aerosol generating. They therefore pose an infection control risk to staff.
  • If patient requires mechanical ventilation then there should be a plan to escalate to invasive ventilation early if required rather than cycling through High-Flow and NIV.
  • If NIV / High Flow are clinically indicated - e.g. chronic NIV use / difficult airway not requiring immediate intubation / risk of intubation outweighs risk of NIV -  patient should be nursed in cubicle (preferably negative pressure) or specific cohort area. Staff must wear PPE as per aerosol generating procedures.
  • BTS / NHS Guidance specific to NIV use in adults with confirmed or suspected Covid-19  can be found here. This may help with paediatric patients.
T-piece and In-line Suction

Bedside Ayres T-piece

This should be fitted with an HME at all times as per photo. The ETCO2 monitor should be distal to the HME to protect the ETCO2 monitor from exhaled gases. The O2 flow must be turned off when not in use to preserve O2 supply.

In-line suction

Must be used when possible.

Come in sizes 8 and 10 (dedicated angle piece with one-way valve –CareFusion) so appropriate for ETT size 4.0 and above. Kept in store cupboard next to HFOV equipment but should be used with conventional ventilator as well. Set up is as below with ETCO2 distal to HME.

Blood gas machine and analysis

Blood gas machine         Liaise with Biochemistry, IT and Estates to ensure Covid-19-dedicated blood gas analyser space is identified.

  • May require erection of temporary structure / screening / hand washing facilities – liaison has occurred between PICU and Infection Control and agreement reached regarding location.
  • Currently a location for blood gas analyser use with confirmed or suspected cases has been identified in Pod 1 of PICU.
  • Blood gases from Covid or suspected Covid patients should only be analysed by this machine to minimise infection control risk.

Blood gas SOP – adapted from Adult ICU Plan

 

Monitoring / Equipment / O2 / Power

Monitoring equipment / modules          

Ensure adequate monitoring and monitoring modules are available to cover expansion into Ward 1E. As of 20/03/20 these are on order.

Site Oxygen Capacity    

  1. The RHC shares an O2 supply with the Adult Hospital / QEUH. The operational supply to the site is 5348L/min.
  2. 30 ventilators running at 15/min equates to 450L/min.
  3. The demand on other areas of the site cannot be predicted by PICU.
  4. Efforts should therefore be made to minimise unnecessary O2 use to preserve supply for surge moments.
  5. PICU Plan:-        
    • Bedside T-piece circuits must be turned to off when not in use – this will save up to 180L/min O2.
    • As with standard good clinical practice the FiO2 on ventilated patients should be titrated downwards to minimise the risk of hyperoxia and preserve the O2 supply.
  6. The manager responsible for the site O2 supply is as follows:- James.Guthrie@ggc.scot.nhs.uk 
    Jim Guthrie 07973711702

Site electricity Supply

  • Planning must be undertaken with estates to plan for surge in electricity supply in event of significant increase in demand for electricity.

Syringe Drivers / Pumps

  • The PICU currently has 94 drivers/pumps with a plan in place to escalate this to 110.
  • Pharmacy ha a plan to minimise driver / pump usage if need be in event of surge – see pharmacy section.
Blood transfusion / ECMO

Blood transfusion / ECMO

  • It is predicted that the blood supply available for transfusion may be limited. This is due to a combination of increased demand e.g. surge in ECMO patients and reduced supply due to donors self-isolating or becoming unwell.
  • Decisions surrounding blood and blood product use must therefore balance the needs of patients with the realities of available blood supply.
  • Consider early or prophylactic use of tranexamic acid in predicted complicated cardiac cases.

ECMO patients as suggested:

  • Hct transfusion trigger of 30 if SvO2 acceptable (and potentially lower as needed which can be dictated clinically)
  • Plat transfusion trigger 75 if open chest and 50 if peripheral cannulation
  • Aggresive use of TXA in any transthoracic ECMO patients for first 24Hrs

 

Pharmacy

Pharmacy plan

Pharmacy is in the process of developing a protocol to minimise the use of syringe pumps to

optimise the availability of these pumps in times of surge. Suggested medications appropriate for

boluses include sedatives and muscle relaxants:- as of 20/3/20 this work is in process and is to be

seen as highly provisional only – click to see provisional work.

IT / Computing Plan
  • Aim to establish dedicated link person within IT / Labs / Estates / Finance early – this has been identified as Simon Trobe. Stefan McLean, IT Manager is aware.
  • Metavision to be expanded into all beds within Ward 1E – will require instillation of network cables and Lantronix boxes in addition to purchasing of additional software licenses. This work is underway.
  • Blood gas analyser to be moved to a dedicated area and separated into “Clean” and “Dirty” Gas analysers with IT support – this has been done.
  • Quote from Metavision for appropriate licenses has been generated and is with management team for final sign off.  In addition an extra 14 Lantronix boxes have been quoted for (update from 20/03/20) and is with management team for final sign off.
Metavision CIS Plan
  • Ensure extra downtime packs available to allow rapid escalation of bed spaces in case Metavision expansion not completed. Must have enough downtime packs to cover whole of Ward 1E.
  • Liaise early with Metavision and IT to ensure expansion plan in place
Administration & Clerical Plan
  • Ensure adequate Metavision CIS downtime packs available, incl ward 1E
  • Bedside nurse must record visitors – this must be made available to Public Health if required
  • Ensure visitors are aware of visiting policy
  • Plan ahead to cover possibility of staffing Ward 1E in addition to PICU
Special circumstances – Patients requiring haemodialysis

Covid positive renal dialysis patients requiring intermittent dialysis

  • Will not be able enter “Clean” Ward 3A where dialysis normally occurs
  • Aim for home haemodialysis if possible
  • If requires hospital haemodialysis then admit into Covid Positive area with haemodialysis point – this is Cubicle 5
  • If Cubicle 5 not available then will need to use Bed Space 15 or 19 – this will require potential re-location of other patients if not already a Covid-19 cohort area.
  • Covid-contact / Covid-suspicion – must be tested prior to admission to Covid-cohort area.
Visitor Policy

Stage 1

Visiting policy as per normal guidelines

Parents at any time other than during procedures as requested.

Friends and family if accompanied by a parent.

Nominated family member may visit unaccompanied if parents unable to visit

Siblings can visit accompanied by an adult/parent

Symptomatic or Influenza positive parents and family members should not visit the department

Stage 2-3

Visiting discouraged

Parents only

Symptomatic parents, or those proven positive for Covid-19, should not visit

Communal visiting areas must be closed

A register of visitors must be kept to be made available to Public Health if required            

Stage 4

No routine visiting from family and parents

Discretionary visiting of parents for infants in imminent danger of death

Significant staffing issues dictate that parents must provide care for their infant

GG&C Covid-specific Visitor Policy

Editorial Information

Last reviewed: 23 March 2020

Next review: 23 April 2020

Author(s): Alastair Turner, Consultant Paediatric Intensivist

Version: 7

Approved By: PICU Guidelines Group