Critical Care Contingency Planning: Phased Responses and Triaging Framework

Abstract

As most of our readers will be aware from previous publications and from the special articles contained in this edition, a lot of work has gone into highlighting the implications of an influenza pandemic for critical care services and trying to work out how to make the best use of the resources that may be available. The latest Department of Health Document ‘Pandemic influenza: surge capacity and prioritisation in health services – provisional UK guidance’ (available on the DH website) has made an encouraging start in providing official recognition of the problems likely to be encountered as a result of limited bed capacity, and also supports the concept that triaging decisions cannot be left to secondary care (and particularly critical care specialists) alone. Regrettably, however, even if its recommendations for patient selection are fully followed and the number of inappropriate referrals to critical care is reduced significantly, there is still a strong probability that during the peak of a pandemic the number of patients who are likely to benefit from critical care will still significantly exceed bed capacity – even if this is maximally expanded.In the original working of the Critical Care Contingency Planning Group a draft document on Phased Responses and Triaging was produced as a starter to addressing these difficulties. Further work on this was then put on-hold pending the production of official ethical guidance and other documentation to address these problems. However, now that these have been finalised and we still face potential dilemmas about how ICUs will be able to cope, feedback from critical care network discussions has persuaded us that it may be useful to circulate a revised version of this document, updated to include more recent recommendations, in the hope that this may be of help in assisting local planning.In particular, the document addresses two concepts that were initially felt to be inappropriate or unacceptable, but which now may be considered reasonable/realistic. These are the possibility of using some method of lottery selection if there are several appropriate referrals but insufficient bed numbers, and the fact that at some point there may be a requirement to accept temporary closure of intensive care to further referrals if no beds are available. It is hoped that consensus support for the principles of this document may help to produce reassurance for staff (with the support of local PCTs and Trust Management) that if potentially preventable deaths occur in such circumstances they will not be vulnerable to litigation or professional criticism when no other treatment options were available.