Transcript Better to serve! PICU / HDU Development

A ‘minor’ pandemic –
stabilisation & management of
critically ill children
Jeff Perring
October 2009
'We're doomed, I say. Doomed'
Or ……
Planning 2002 to 2009
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Expected a “bird flu” outbreak in humans
Experience of several small clusters
High mortality
Severe disease
Expected high transmission rates
Expected would arise in far East
“No battle plan ever survives contact with the
enemy”
Field Marshal von Moltke (1848-1916)
Australasia
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First wave in their winter
Close to being overwhelmed
Less impact on children but still bad
DH Surge capacity
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Plan to increase critical care capacity by 100%
Sustainable for a period of up to 3 months
Recognised that only a basic or limited level of
critical care may be possible
Adapted ways of working and clinical practices
NHS Emergency Planning Guidance 2005: underpinning materials
Critical Care Contingency Planning in the event of an emergency where
the numbers of patients substantially exceeds normal critical care capacity
Department of Health, 2007
What is ‘basic or limited’ care
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Not intensive care as we know it
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Staff
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Rather best possible with available resources
Reduced nursing ratio
Reallocated from non-essential areas
Poor skill mix / limited specialist skills
High absentee rate
Unfamiliar environment
But……
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Many children admitted to ICU have required
high end intensive care
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HFOV
CVVH
ECMO
Network
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General ICU’s may have to admit children
Network support and education
Telephone advice provided
Transfer smallest sickest children in and older,
less sick children out
How to treat?
Principles
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The ‘Pareto Principle’
Or the 80:20 rule
Pandemic H1N1 Influenza
Draft DOH paediatric practice
notes
Background
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Impact of second wave unclear
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Return to school
Disease is complicated by co-circulating winter
pathogens such as RSV
Introduction of vaccination
Presentation
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Median age 9 years
Most with co-morbidities
Cough, tachypnoea and fever
Encephalopathy
Shock
Diarrhoea & Vomiting
Respiratory disease
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Hypoxia common indication for ICU
Critical care outreach and PEW
Disease may be fulminant
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Presentations
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Early and aggressive treatment
Bronchiolitic type illness
Lobar pneumonia
ARDS
NIV reserved for moderate cases or until resources limited
HFOV
ECMO
Diuresis, fluid restriction +/- CVVH
Cardiovascular disease
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Shock is not uncommon at presentation
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Aggressive fluid resuscitation and early use of
inotropes
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Target urine output, lactate etc
Catecholamine resistant shock occurred in three of
the eight UK cases
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8/13 in a UK series
Septic picture of high output and low SVR
Vasopressin/steroids
Myocarditis has been described
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Echo
Neurological disease
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Seizures and status epilepsy, associated with high
fever seen at presentation
CT scans recommended
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Cerebral oedema and infarction seen
Prognosis in isolated neurological presentation
outside critical care appears good
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Acute neurological symptoms should not limit other
therapy, except where clear evidence of an irreversible
deficit exists
Microbiology
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Nursed in isolation
Cohort once H1N1 confirmed
Oseltamivir started on clinical grounds before testing
confirms the diagnosis
NPA plus ETT aspirates or non directed bronchiolar
lavage
Once extubated, symptom free, uncomplicated cases
who have completed 5 days of antivirals need no
longer be isolated
Microbiology - continued
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Continuing infection control
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Concurrent bacterial infection reported with
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Recommended when caring for patients who require
prolonged intensive care
Pneumococcus
Staphylococcus
Group A streptococcus
CRP, white cell count not helpful in identifying
patients
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Clinical suspicion should be high in the critically ill
population before culture results are available
Other treatment advice
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Information available:
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www.criticalcarenetwork.sch.nhs.uk
Information available
Available on the website
For pandemic flu
Guide to intensive care
And for potential transfers
Problem 1
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Reduced staffing levels, an unfamiliar
environment and high stress levels will result
in:
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b)
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Reduced standards of care
Increased errors / mistakes
Children under our care will be harmed but
to what level?
Support from governing bodies?
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In an emergency, wherever it arises, you must offer assistance, taking account of
your own safety, your competence, and the availability of other options for care.
In a pandemic, this means that you may work outside your normal field of
practice, either in providing care to patients with influenza, or patients with other
conditions
GMC: Good Medical Practice
Responsibilities of doctors in a national pandemic
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7. You must recognise and work within the limits of your competence although this should not be used to
avoid providing care when it is needed because the setting is unfamiliar. If in doubt, find out from your
employer what is expected of you and seek additional support or training as necessary.
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10. In considering any complaint made about a nurse or midwife working during the swine flu pandemic,
the Nursing & Midwifery Council will take all the issues into account. This could include the resources
available to the nurse or midwife and the problems of working in unfamiliar areas of practice. The
primary requirement for all nurses and midwives is to respond responsibly and reasonably to the
circumstances they face. You remain accountable for actions and omissions in your practice and must be
able to explain your actions, if asked to do so.
Nursing and Midwifery Council
New position statement on the role of registered nurses
and midwives during an influenza pandemic (14 October 2009)
Problem 2
Demand exceeding supply
The bottom line
The allocation of finite resources during
a pandemic will necessarily result in the
deaths of patients (children) who, under
normal circumstances, would have
survived their illness
Basic principles
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Everyone matters
Everyone matters equally
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Does not mean that everyone is treated identically
The interests of each person are the concern of all of
us, and of society
The harm that might be suffered by every person
matters
Department of Health. Responding to pandemic influenza. November 2007
Individual principles
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Respect
Minimising the harm that a pandemic could cause
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‘Physical, psychological, social and economic harm’
Fairness
Working together
Reciprococity
Keeping things in proportion
Flexibility
Good decision making
Department of Health. Responding to pandemic influenza. November 2007
Surge Response
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Prioritisation criteria
Restrictions on treatment
options
Introduced when necessary
in locality
Short a period as
practicable
Child A
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8 years old with SMA
If he develops pandemic influenza will probably
require prolonged PICU course
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2 / 3 patients may be unable to access ICU because of him
Once extended capacity reached we should consider
withdrawing his intensive care
But he has a good quality of life outside of ICU and
a reduced but unknown life expectancy
What should we do?
What will be the effects of our actions?
Utilitarian approach
‘The creed which accepts as the
foundation of morals, Utility, or
the Greatest Happiness Principle,
holds that actions are right in
proportion as they tend to
promote happiness, wrong as
they tend to produce the reverse
of happiness’
John Stuart Mill; Utilitarianism
Outcomes rather than actions
What is the foundation of our ethics?
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Best interests
4 principles of medical
ethics
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Autonomy
Non-maleficence
Beneficence
Justice
‘Always recognize that human
individuals are ends, and
do not use them as means
to your end’
Immanuel Kant 1724 - 1804
Best interests
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An act done, or decision made, under this Act for or on behalf
of a person who lacks capacity must be done, or made, in his
best interests
Mental Capacity Act 2005 Part 1 Principles (5)
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Doctors have an ethical obligation to show respect for human
life; protect the health of their patients; and to make their
patients' best interests their first concern
Withholding and withdrawing life-prolonging treatments:
Good practice in decision-making (9). GMC 2006
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Where patients lack capacity to make decisions for
themselves, the test that must be applied to determine whether
treatment should be provided is ‘best interests’
Withholding and Withdrawing Life-prolonging Treatment (9.1).
BMA 2007
Rights based approach
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Everyone’s right to life shall be protected by law. No one shall be
deprived of his life intentionally save in the execution of a sentence of a
court following his conviction of a crime for which this penalty is
provided by law.
Human Rights Act 1998. Article 2 Right to Life
In all actions concerning children, whether undertaken by public or
private social welfare institutions, courts of law, administrative authorities
or legislative bodies, the best interests of the child shall be a primary
consideration (3)
Parties recognize that every child has the inherent right to life (6.1)
Parties recognize that a mentally or physically disabled child should enjoy
a full and decent life (23.1)
UN Convention on the Rights of the Child 1990
RCPCH
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Decisions should not be rushed and rigid rules, even for conditions which
may seem hopeless should be avoided. Discussions with the parents
should be undertaken 'on the basis of knowledge and trust' (3.1.1)
The Ethics Advisory Committee of the RCPCH stated that they 'do not
feel that decisions about the sort of child who would be offered intensive
care should be resource motivated but should be determined by whether
such care was appropriate' (5.2)
Where appropriate to withhold or withdraw care:
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The Brain Dead Child
The Permanent Vegetative State
The No Chance Situation
The No purpose Situation
The Unbearable Situation
Withholding or Withdrawing Life Sustaining Treatment in Children
- A Framework for Practice. RCPCH. 2nd edition. May 2004
The GMC
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‘The investigations or treatment you
provide or arrange must be based on
the assessment you and the patient
make of their needs and priorities,
and on your clinical judgement
about the likely effectiveness of the
treatment options.
However, in a pandemic it may not
be possible to respond fully to
patients’ preferences or priorities…
It will be particularly important to
ensure that decisions you make in
relation to provision of care are fair
and based on clinical need and the
patient’s capacity to benefit…’
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‘You must give priority to the
investigation and treatment of
patients on the basis of clinical need,
and on the patient’s likely capacity
to benefit, when such decisions are
within your power.’
SC(NHS)FT Position
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Patients should not be considered for critical care admission when
intensive care is considered not to be in their best interests
Where two or more children are eligible for admission to critical care but
only a single bed is available the final decision on who is admitted should
be made by three senior clinicians and well documented.
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It should be based upon clinical experience as to which of the children, at that
moment, would benefit most from intensive care.
This form of triage should only take place when all actual and potential
ventilated beds have been filled
The Department of Health recommends that service providers use ‘generic
admission assessment tools appropriate to their service to help guide the
placement of patients or clients in the appropriate level of care’. These
tools may aid but not determine clinical decisions. An equivalent tool for
paediatrics is neither validated nor available.
SC(NHS)FT Position
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A form of ‘reverse triage’ will be used
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Based upon the premise that ‘the potential medical benefits to
incoming patients should ideally be greater than the potential risks of
not receiving care for those discharged’
Patients on PCCU will be regularly assessed as to whether they are fit
to be discharged
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Care will not be withdrawn on any child unless the criteria laid out
in the Royal College of Paediatrics and Child Health (RCPCH)
document on Withholding or Withdrawing Life Sustaining
Treatment in Children is met.
Legal advice to the Trust is that withdrawing treatment on intensive
care when it is not in the child’s individual best interests to do so
would be ‘unlawful’
Where does this leave us?
‘During overwhelming disasters,
health systems must be
considered lifeboats with
insufficient capacity to minister
to all, and thus decisions
regarding who is best served by
the lifeboat must be made.
Under this tenet, inpatients, disaster
victims, and others with acute
care needs must be considered on
equal terms and compete for
limited resources.’
Titanic Lifeboat
14 / 15 April 1912
NHS Emergency Planning Guidance 2005: underpinning materials
Critical Care Contingency Planning in the event of an emergency where
the numbers of patients substantially exceeds normal critical care capacity
Department of Health, 2007
“What we learn in times of pestilence is that
there are more things to admire in men than to
despise.”
Albert Camus
Any questions?