Coping with an Influenza Outbreak! Gavin M Joynt The Chinese University of Hong Kong

Transcription

1 Coping with an Influenza Outbreak! Gavin M Joynt The Chinese University of Hong Kong

2 SARS (2003)/H1N1 (2009) - pandemic lessons for ICU

3 Updated preparedness and response framework MMWR Recomm Rep Sep 26;63(RR-06):1-9.

4 Preparation will determine how well we cope CDC Planning and Preparedness Resources

5 What we learned about ICU during and after the SARS/H1N1 pandemic Expansion capability is limited Infection control (protecting staff) is difficult Triage Be cautious with experimental therapies

6 Experience of excess expansion Infectious Diseases Hospital in HK (1200 beds) 86 isolation beds 14 ICU beds Designated to admit 1000 SARS cases Legislative Council Select Committee to inquire into the handling of the SARS outbreak by the Government and the Hospital Authority

7 Expansion ICU plan - increase from 14 to 64 beds over 1 month Convert wards and buy equipment Staff Doctors 6 to 28 Nurses 56 to 240 No concerns raised by medical management.. it was the Government s decision Legislative Council Select Committee to inquire into the handling of the SARS outbreak by the Government and the Hospital Authority

8 What happened? 40 ICU SARS patients by end of week 1 Staff were.. overstretched 9 [18] doctors of whom 5 were junior medical officers with about 80 [160] nurses. insufficient trained doctors and nurses in HK Legislative Council Select Committee to inquire into the handling of the SARS outbreak by the Government and the Hospital Authority

9 Consequences 25 Health Care Workers were infected, more than half in this first week Staff Unfamiliar with IC protocols Unfamiliar with the environment Unused to work in ICU Equipment deficiencies Scavenging, filters, PPE etc. Of doctors.. only 1 specialist and 2 medical officers of the original team remained.even the ICU director was admitted with SARS.. Legislative Council Select Committee to inquire into the handling of the SARS outbreak by the Government and the Hospital Authority

10 Consequences Patients diverted to other (non-id) hospitals in HK High raw mortality rates Limited outbreak data so impossible to even estimate the cost in terms of patient morbidity/mortality

11 ..Overestimated the expandability of the ICU. Legislative Council Select Committee to inquire into the handling of the SARS outbreak by the Government and the Hospital Authority

12 Expansion limiting resource

13 Nurses are critical Doctors can see a patient and walk away Nurses continuous monitoring and troubleshooting labor intensive activity Less possibility to extend their sphere of activity Intensive Care Med. 2006;32: DOI /s

14 Nurses become the expansion limiting resource Increase in 25% to allow rest time and time to don and remove PPE PPE, senses (hearing and sight), may increase nursing intensity, IC protocols limit movement between patients Because of the critical care skills required, no more than 1 new recruit for each experienced or resident nurse

15 Nurses Net effect, based on feasibility ICU bed number cannot be increased by more than 60% Sickness 40-70% of staff may not be able to work in an influenza pandemic Rubinson et al. - lower level of intensive care to a greater number of patients Intensive Care Med. 2006;32: DOI /s Rubinson L, Nuzzo JB, Talmor DS, et al. Care. Crit Care Med 2005; 33: 2393

16 To expand within a feasible limit Pre-emptive organized recruitment Lists of doctors and nurses with previous ICU experience Recruitment of surgeons and anaesthetists and accompanying nurses Proper up to date registers (transparent process) Mask fit tested Rapidly upskilled

17 Time consuming!!

18 Mask pass rate on an ICU health provider population Pass (%) A B C D E F G H I J K L M N O P Q R S T U N95 masks MMWR 1998; 47:1045-9

19 Recruit training (e-learning) Joynt GM et al. J Crit Care, 2011;26:533.e1-533.e10.

20 Facilities (preparation is key) Airborne Infection Isolation Rooms Design/air changes etc. New unit design Workflow Gown up and gown down areas Siegel JD, et al., and the Healthcare Infection Control Practices Advisory Committee 2007 Guideline for Isolation Precautions in Healthcare Settings Intensive Care Med. 2006;32: DOI /s Sprung CL et al. Intensive Care Med 2010;36:428-43

21 Options if overwhelmed Expand Greater expansion possible, but with reduced level of care and likely staff risk Reallocate ICU resources Ration ICU beds - Triage

22 Ontario Health Plan for an Influenza Pandemic (OHPIP) triage protocol Two-stage process to exclude patients Stage 1 - severe co-morbidity Stage 2 - prioritized on the basis of SOFA Christian MD et al. CMAJ 2006; 175:1377 Modeled mortality Refuse admission Mortality of SOFA > 11 in pts with H1N1 (31%) Withdrawal in ICU Mortality of those in whom SOFA rose to > 11 (28-55%) Shahpori R, et al. Crit Care Med 2011; 39:827

23 Influenza 80 % of reported cases MOF RS CVS Renal Hepatic Haematological CNS GI Gruber PC, Gomersall CD, Joynt GM. Intensive Care Med, 2006; 32:823

24 SARS % of patients RS CVS Renal Hepatic Haematological CNS Gomersall CD, Joynt GM, Lam P et al. Intensive Care Med, 2004; 30(3):

25 Cautions Scoring system must reflect disease severity profile Difficult to achieve sufficient data to develop a robust score during the epidemic Variable prognostic features depending on agent of injury e.g. H1N1 Vs H5N1 have different rates of organ failure Triage thresholds may evolve Regional patient loads may differ Readjustment of benefit required for meeting admission criteria as epidemic waxes and wanes (recalibration) Gomersall CD, Joynt GM. Critical Care Med 2011;39:911

26 Infection Control Measures No. of admissions/new staff infections Day 5/187 (3%) - all cases were nurses Gomersall CD, Joynt GM, Ho OM et al. Protecting health care workers from SARS

27 Infection control measures Vs time Segregated entry and exit Hoods for high-risk procedures Eating cubicles Checkpoint at entry/exit Full face-shield at all times Full face-shield for high risk procedures Visor Cap No NIPPV N95 Waterproof gown Water repellant gowns No. of admissions/new staff infections Day

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30 Courtesy of Prof Gary Settles, The Gas Dynamics Laboratory, The Pennsylvania State University, 301D Reber Building, University Park, PA

31 NIV BiPAP 18/4 cmh 2 O Hui DS, Hall SD, Chan MTV et al. Chest 2006; 130:730-40

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33 Microbes are usually shed everywhere!!!

34 Medication use MRSA, empirical Antibiotics and PPE Novel and unproven remedies Yap FHY et al. Clin Infect Dis 2004; 39: 511-6

35 Yap FHY et al. CID 2004; 39:

36 Yap FHY et al. CID 2004; 39:

37 Why? Continuous gloving within the ICU Inanimate reservoir for MRSA Reduced compliance with hand washing Horikawa K et al. Microbiol Res 2001; 155: 345 Boyce JM et al. Infect Control Hosp Epidemiol 1997; 18: 622 Interaction between SARS Co-V and MRSA Explosive airborne dispersal - the cloud phenomenon Bassetti S et al. Clin Infect Dis 2005; 40: 633

38 Beware side-effects - unproved therapy Griffith J, Antonio GE, Kumta SM et al. Radiology. 2005; 235:168-75

39 Data collection Early ethics approval Large databases Establish incubation period, time to ICU admission, ICU LOS, mortality rates etc. as quickly as possible Clinical decision making Resource use (LOS) Triage (prognosis, outcomes) Rowan KM et al. SwiFT study. Health Technol Assess 2010;14: Fowler RA, Webb SA, Rowan KM et al. Early observational research and registries during the influenza A pandemic. Crit Care Med 2010;38(4 Suppl):e120-32

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42 Intensive Care Med 32 (6): , Expanding ICU facilities in an epidemic: recommendations based on experience from the SARS epidemic in Hong Kong & Singapore Gomersall CD, Tai D, Loo S et al. Intensive Care Med, 2006; 32(7): Pandemic preparedness Gomersall CD, Loo S, Joynt GM, Taylor BL. Curr Opin Crit Care 13 (6): , 2007.