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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:-
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:
Acute Stage 2
Pandemic Covid-19 affecting NHSGGC; small increase in ICU demand
Acute Stage 3
Pandemic Covid-19 affecting NHSGGC; moderate increase in ICU demand
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.
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.
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:
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.
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.
Current situation:- We have 29 mechanical Ventilators in PICU. This includes:-
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
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.
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
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.
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 Liaise with Biochemistry, IT and Estates to ensure Covid-19-dedicated blood gas analyser space is identified.
Blood gas SOP – adapted from Adult ICU Plan
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
Site electricity Supply
Syringe Drivers / Pumps
Blood transfusion / ECMO
ECMO patients as suggested:
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.
Covid positive renal dialysis patients requiring intermittent dialysis
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
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
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
Last reviewed: 23 March 2020
Next review: 23 April 2023
Author(s): Alastair Turner, Consultant Paediatric Intensivist
Approved By: PICU Guidelines Group