The doctors, nurses, allied health professionals and researchers who comprise the Australia and New Zealand Intensive Care Society (ANZICS) continue to help the Australian and New Zealand communities during the COVID-19 pandemic. Our members provide high quality, compassionate and professional care to the most vulnerable members of our communities every day and this commitment will not change.
As seen in previous disasters, the COVID-19 pandemic will further expose pre-existing inequities in chronic health outcomes and health service delivery. We recognise that the Aboriginal and Torres Strait Islanders of Australia and the Māori of Aotearoa New Zealand are over-represented in disadvantaged populations in ways that make them far more vulnerable to pandemic disease. Indigenous communities in Australia and New Zealand have been disproportionately impacted by previous pandemics. We advocate for the best possible access to and provision of critical care support for these groups. We also advocate for specific input from Aboriginal and Torres Strait Islander and Māori communities in national and jurisdictional COVID-19 response programs.
ANZICS strongly supports state, national and international efforts to reduce the spread of pandemic illness through effective public health measures (i.e. social distancing and masks). This approach is supported by high-quality evidence and significantly mitigates the impact on Intensive Care Unit (ICU) capacity, which is a finite resource.
ANZICS strongly supports vaccination and a population vaccination target of greater than 80% (currently in those over the age of 16). Vaccination, in addition to reducing the incidence of COVID-infection, has been shown to reduce severe disease and death. Countries with a high vaccination rate have shown a clear reduction in the number of COVID-19 infections requiring ICU admission.
ANZICS strongly supports mandatory vaccination for all healthcare workers who can be vaccinated against COVID-19, with an appropriate program developed for boosters as required.
ANZICS recommends all staff have access to appropriate Personal Protective Equipment (PPE) including fit-tested N95 masks or an appropriate alternative.
ANZICS recognises that patients without COVID also suffer in a pandemic and supports strategies to maintain access to elective surgery and healthcare for all patients.
The most important resource in Australian and New Zealand ICUs is experienced Intensive Care staff, who are trained to provide high-quality care for critically ill patients. The delivery of this service must be supported by government policy and community behaviour.
It is essential that local and jurisdictional ICU pandemic plans be developed, resourced and implemented where appropriate by all healthcare organisations and that plans align with health department requirements. Pandemic plans should include operational approaches to reduce routine ICU demand, identify and increase physical ICU bed space capacity throughout the hospital, and determine equipment and workforce requirements.
It is essential that jurisdictions plan for sustained increased capacity rather than for defined periods of surge. There is clear evidence that mortality increases as a health system experiences ICU demand beyond usual capacity. Even in countries with high rates of vaccination, a consistent level of COVID-19 related ICU admissions persists, albeit with a large proportion from the unvaccinated population. ICU staff often work more in times of need, but this leads to fatigue and burnout and poorer outcomes for patients. The focus therefore needs to be on a sustained safe and effective workforce. We recommend collaboration between area health systems, load rebalancing and mobilisation of staff to assist in times of increased demand.
We recommend ICU operational status be monitored and reported in an expeditious manner to facilitate decision making processes, minimise system strain and maintain the standards of care required to achieve optimal patient outcomes. Effective information sharing to ensure delivery of the right information to the appropriate persons in a timely manner, is central to an effective pandemic response. We recommend ongoing support and funding for the Critical Health Resource Information System (CHRIS).
We recommend that ICU operational status be described in terms of both staffing and physical capacity, in recognition that a match between appropriate staffing and adequate infrastructure is central to the delivery of effective critical care services. This is demonstrated in Table 1 with a corresponding tiered, colour coded description of the current status.
We recommend that all efforts be made to ensure critically ill patients are cared for in ICUs with adequate staffing and physical resources with minimal compromise to usual models of care. A whole-of-health system approach involving both jurisdictional authorities and ICUs is absolutely necessary.
We recommend that ICUs do not enact individual surge plans or change models of care while there is still capacity in nearby areas. Partnerships, such as between private and public hospitals, adult and paediatric ICUs, and through telehealth arrangements to support different level ICUs, should be considered to ensure just and equitable delivery of care for all critically ill patients. This ensures the best clinical care and outcomes for critically ill patients.
We recommend that healthcare jurisdictions develop a phased response based on the impact of the pandemic on the operational status of the ICU. Demand for ICU capacity due to COVID-19 infection is likely to fluctuate across the duration of the pandemic and local authorities should develop triggers for escalation and de-escalation of their response. ICUs in Australia and New Zealand should aim to continue to operate with usual models of care (within the “green zone” in Table 1) as far and for as long as possible.
We strongly recommend that healthcare jurisdictions utilise periods of low case numbers to address staffing and infrastructure deficits for predicted future demand. It is likely that once vaccination targets are reached, government policies around border closures and lockdowns will be relaxed and a rise in cases will occur, albeit mitigated by vaccination.
A whole-of-health system approach requires mechanisms to have a broad overarching view of current demand as well as projected demand. As a key determinant of capacity, and to improve access to ICU care for patients, visibility of immediate workforce availability is crucial.
We recommend the development of a framework to determine risk in order to support planning and the appropriate use of available resources. The components of this framework should include information on local prevalence, epidemiology of clusters, rate of new COVID-19 cases, variants of concern and the level of control measures in the community. Current Australian experience suggests that approximately 1% of identified community cases are admitted to ICU. Determination of risk can contribute to guidance on the use of PPE as well as the level of elective surgery performed.
We recommend establishing central coordination, involving senior clinicians, of ICU beds/capacity and transfers within each health system. It is recommended this be enacted whilst working within standard capacity to test the system, and identify and address any issues prior to more advanced phases of the pandemic.
We recommend regular meetings of ICU heads of departments (medical and nursing) within jurisdictions to address issues relating to significant differences in demand between ICUs. We recommend the use of local and national dashboards (e.g. the CHRIS dashboard) to help guide decision making.
The movement of patients between units may be required to ensure an equitable distribution of patient numbers and workload. The logistics of staff redeployment to areas of need should be explored early.
Communication within a pandemic is crucial to the successful delivery of safe and effective clinical services. The ever increasing volume of information and literature, research trial engagement and data, evolving guidelines, policies and procedures requires management and streamlining. Priority areas in information dissemination include daily situation reports at a local, regional and state level.
The following measures should be considered to reduce the overall as well as regionalised demand for critical care services and should be enacted before demand exceeds capacity.
Regionalisation of outbreaks can create strain on some hospitals more than others. Subsequent transport of critically unwell patients between hospitals to address strain requires significant resources and time. With the understanding that patient transport and retrieval services have a limited capacity, ANZICS recommends exploring upstream diversion of patients before they present to the first hospital.
Streaming will require system-wide visibility of the ambulance network, ED, ward and ICU capacity.
A substantial proportion of patients admitted to ICU will require testing for COVID-19 infection, particularly during periods of widespread community transmission, and subsequent clearance through polymerase chain reaction (PCR) testing. A delay in test results increases the demand on ICU resources, including staffing and the use of PPE.
ANZICS recommends the establishment of processes which prioritise and expedite the return of COVID-19 results for patients in ICU and other critical care areas (e.g. emergency department and operating theatres). All ICU patients for whom COVID testing is indicated should have rapid testing due to the resource implications and higher intensity of care required.
Deferment of elective surgery has significant public health implications and should be time limited. Exploration of all options should take place at early stages with the aim that elective surgery is supported throughout the pandemic. This includes load sharing within the public system and outsourcing to private facilities.
The decision to defer or cancel surgery will depend upon the impact of the pandemic on the operational status of the ICU. These decisions should involve ICU, surgery, anaesthesia and nursing services.
Interruption of elective surgery during amber and red phases will have significant public health implications but may still be necessary for short periods. The black phase will require cancellation of all elective surgical cases (including minor elective and day surgery). This will allow for staff redeployment, improved patient flow and conservation of PPE.
We recommend implementing safe processes to expedite patient discharge from ICU during phases of increased demand. These may include additional support for ward staff to manage patients of higher acuity, or improving flow in discharging patients to areas with greater clinical oversight (e.g. neurosurgical HDUs).
We recommend that ICU specific protocols for the de-escalation of COVID-19 isolation measures be developed in consultation with infection control and infectious disease departments and with consideration of relevant guidelines e.g. the Communicable Disease Network Australia (CDNA).
These patients are likely to have prolonged stays and involvement with allied health and rehabilitation services. We recommend a multi-disciplinary handover process and establishment of goals of care for all ward transfers.
In more advanced stages of the pandemic (red and black phases), ICU admission should be prioritised for those who require specific ICU interventions such as mechanical ventilation and organ support. This may necessitate the following:
We recommend early consideration of treatment goals to avoid ICU/HDU referrals or admissions in patients more appropriately managed on the ward. This may be facilitated by ensuring that all patients have documented goals-of-care or equivalent completed upon hospital admission.
ANZICS recommends patients are transferred to an ICU with capacity and appropriate infrastructure, rather
than remain in an ICU at capacity or with strained staffing and/or resources.
In addition, we recommend that all clinical areas with the physical infrastructure suitable to care for critically ill patients should be identified as part of hospital preparedness plans. These include (but are not limited to):
Criteria for high dependency area bed spaces (called ICU2 in some jurisdictions) are available via the College of Intensive Care Medicine guidelines.
We recommend hospital executive work with ICU clinicians to develop processes enabling the repurposing of these areas when needed and in establishing workforce models that allow for appropriate critical care staffing across multiple locations. The ability to meet the above standards may be limited in the advanced phases of a pandemic, necessitating adjustments based on the clinical needs of the patients and available resources.
We recommend visibility of central supply stocks of equipment (at state level) as well as transparent plans
for distribution to allow feedback and planning for increased demand.
We recommend ICUs should quantify current stocks of equipment (e.g. ventilators, renal replacement
therapy, infusion pumps) including consumables and disposables as well as assess potential requirements
with increasing ICU load. ICUs should also identify available channels for the supply, storage, and procurement of additional equipment.
This may include:
It is likely that staff shortages and in particular critical care nursing, will be the greatest limiting factor on ICU capacity when there is widespread community transmission of COVID-19 infection. The high chance of staff furlough and potential healthcare worker infections means a significant proportion of ICU staff may be absent from the workplace during advanced stages of the pandemic. The COVID-19 pandemic has also resulted in limited immigration which has had a significant impact on critical care medical and nurse staffing across Australia and New Zealand.
Due to these potential workforce shortages, non-critical care trained medical, nursing and allied health staff may have to assist in the care of ICU patients. This should occur with the relevant managerial authorisations, and under the supervision of critical care trained staff, utilising a team-based model of care.
ICUs and hospitals should prioritise meeting the minimum standards for staffing as per the College of Intensive Care Medicine and the Australian and New Zealand Colleges of Critical Care Nursing guidelines. However, available resources may change depending on the demand placed upon a health service.
We recommend workforce planning should include consideration for pandemic specific requirements, such as additional workload from donning and doffing of PPE, the need for additional rest days, and the need to allocate staff to key non-clinical duties such as enforcing infection control procedures. Healthcare jurisdictions must also account for staff furlough, which is likely to occur with staff exposure in the setting of community transmission.
We recommend the use of all available resources to optimise workforce capacity, by identifying and potentially redeploying nursing, medical, allied health and other staff.
We recommend that core ICU staff maintain operational readiness through ongoing education, simulation and revision of COVID-19 protocols during periods of low community viral transmission. We recommend that where staff are requested to perform duties outside their usual scope of practice due to severe workforce shortages (e.g. anaesthetists taking on an intensivist role), this should be at their discretion, with adequate supervision and orientation and with jurisdictional reassurance regarding indemnity coverage.
We recommend data collection and research be considered essential services to help guide future directions through the pandemic. These activities must be supported and if needed, alternatives explored to ensure they continue.
We recognise the importance of training and supporting healthcare students throughout the pandemic for a future sustainable workforce. During advanced phases of the pandemic, significant strains on staffing may not allow traditional student teaching.
We recommend exploring other options such as utilising students for appropriate roles in team-based models of care.
If students are undertaking such roles, then we recommend that they should be paid for such roles and consideration be given to having an agreement with the health service to ensure they are provided with appropriate indemnity cover, liability insurance and Workcover protection.
Many patients who survive an episode of critical illness go on to develop more chronic impairments of physical, cognitive and psychological health, recognised collectively as Post-Intensive Care Syndrome (PICS). Family members may also experience mental health impacts recognised as Post-Intensive Care-Family (PICS-F).
Data suggests a proportion of COVID-19 sufferers develop long-term health impairments, referred to as “long COVID-19”. Risk factors for the development of prolonged health impairments include pre-existing frailty and functional impairment, a prolonged ICU stay, delirium and sepsis. Following discharge from ICU, depression, anxiety and the development of post-traumatic stress disorder increase the risk of long-term impairments.
In Australia, many of those who were critically ill with COVID-19 have reported new problems with physical, cognitive and psychological function at 6 months after the acute illness, similar to the experiences reported internationally (Table 3).
Prior to and/or following hospital discharge, ANZICS recommends that:
Due to the highly transmissible nature of this disease, strict ICU visitation controls are necessary. It is recognised that this can contribute to complicated grief for members of the public and moral distress for healthcare workers. Therefore, ANZICS endorses the position statement on facilitating next-of-kin visitation, jointly endorsed by the Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control.
Family visitation may be considered appropriate in certain circumstances (e.g. during end-of-life care). Visitor safety is paramount; hence family visitation should be in alignment with jurisdictional recommendations, and where local resources and staffing permit.
Family visitation should be limited to the next-of-kin or immediate family, who must be deemed fit and well, not self-isolating due to COVID-19 exposure, and not currently COVID-19 positive.
A member of the ICU team should take responsibility for informing visitors about how the visit will be conducted, pre and post-visit hygiene requirements, use of PPE, anticipated timing and duration, and provide instructions for the bedside visit. On arrival, family visitors should be assisted to don PPE and escorted to the bedside. Where possible, the family/ visitors should be provided with time alone with the dying person. At the end of the visit, an ICU staff member should assist the family visitor to doff all PPE and exit. Where warranted, immediate emotional support should be provided, and details of additional support services such as pastoral care or bereavement support services provided.
ANZICS recognises that patients in remote, rural and regional areas are at additional risk of health disadvantage in a pandemic. We advocate for geographical equity through the maintenance of usual standards of care for all patients. This includes the availability of sufficient resources such as equipment and workforce, ongoing access to clinical trials, contributions towards jurisdictional databases (e.g. CHRIS, ANZICS APD/ANZPICR) and timely support for patient management.
ANZICS recognises that remote communities are at increased risk and supports jurisdictional decisions to protect these communities through public health measures until appropriate vaccination targets are met.
ANZICS strongly supports the recommendations in the Australasian College for Emergency Medicine’s COVID-19 Toolkit for Rural Emergency Care Facilities in Australasia. This document contains an audit tool for remote, rural and regional health services to assess their critical care capacity and ability to provide ventilatory support.
The most likely rate-limiting factor in supporting remote, rural and regional critically ill patients during the pandemic is critical care qualified nurses. There will also be shortages of medical and allied health staff. Health services with staffing models relying on fractional appointments, fly-in-fly-out (FIFO), locum and/or agency staff are at particular risk.
Mobilisation of staff to non-metropolitan areas has additional logistical challenges related to geography (e.g. accommodation and transport) that require consideration. The ability to utilise team based rostering to mitigate the risk of staff cross-contamination and reduce the impact of staff furlough is logistically more challenging in rural and regional settings.
We advocate for a centralised process to mobilise critical care trained staff to areas of need during local outbreaks of the pandemic. This may include periods where large numbers of healthcare staff are furloughed.
In facilitating the care of critically ill patients in remote, rural and regional health services, We recommend:
We recommend consideration of regional hubs to centralise staff and resources. The capability of the hub needs to be defined, measured and resourced with appropriate metrics. The hubs should aim to care for lower acuity patients with clear triggers for transfer to metropolitan centres.
In planning to expand health service capacity, we recommend:
In the event that health services are expected to manage ventilated patients beyond existing capacity, we recommend:
In health services unable to provide invasive ventilation, we recommend:
In order to maintain a workforce with the necessary knowledge and skills and to ensure that staff stay informed of changes in COVID-19 management, we recommend:
ANZICS recommends expanding the use of telehealth and virtual care services to provide additional advice and support to health care staff in facilitating improved local care and patient transfer considerations.
ANZICS recommends a central telehealth service or that metropolitan and larger regional units take responsibility to provide telehealth support to smaller regional units. Daily virtual ward rounds in advanced stages of the pandemic should be considered.
Fear and anxiety during the pandemic may be more pronounced for remote, rural and regional staff for multiple reasons including the increased risk of treating friends, family or colleagues, heightened resource restrictions and challenging clinical conditions.
ANZICS recognises that psychological support can be more challenging in rural and regional areas. We advocate for equity of access to resources that support staff wellbeing and psychological stress mitigation.
When compared with adults, COVID-19 infection is an uncommon cause of severe or critical illness in children. Most children with COVID-19 are asymptomatic or have only mild respiratory signs, but between 2 and 20% of hospitalised children with COVID-19 infection may need ICU admission. This is based mainly on data from childhood infection with the Alpha variant.
Children under 12 years will remain a vulnerable cohort if they are not included in the vaccination programme. There has not been modelling of the impact on paediatric critical illness and PICU admission of the Delta strain as a single infectious agent or as co-infection with Respiratory Syncytial Virus (RSV) or other respiratory viruses.
Children with chronic underlying diseases are susceptible to serious complications of COVID-19 infection. Paediatric patients with cerebral palsy, chronic lung disease, congenital heart disease, type 1 diabetes, immune problems and cancer, are more likely to be hospitalised and are at higher risk of dying than the general paediatric population. Adolescents with obesity or hypertension are also at an increased risk of complications.
Clinical manifestations of COVID-19 infection in children may differ from adults. In addition to the more commonly seen manifestations such as pneumonitis, COVID-19 infection may lead to a generalised viral illness, with high fever (T>39 C), erythematous rash, diarrhoea and vomiting.
Rarely, COVID-19 in children is associated with a delayed hyper-inflammatory syndrome called Paediatric Inflammatory Multisystem Syndrome – temporally associated with SARS-CoV-2 (PIMS-TS). This can appear similar to Kawasaki disease and toxic shock syndrome and may be fatal. PIMS-TS may occur during an acute COVID-19 pneumonitis or more commonly 2-4 weeks afterwards when evidence of COVID infection may only be manifest by detection of COVID antibody.
We recommend that the identification and management of COVID-19 infection in paediatric patients is in accordance with the National COVID-19 Clinical Evidence Taskforce https://covid19evidence.net.au/.
Physical distancing and mask wearing reduces the incidence of unplanned paediatric ICU admissions with seasonal respiratory illness. Additionally, the deferment of non-urgent elective surgery during periods of widespread COVID-19 transmission may increase PICU bed capacity.
It is possible that PICU clinicians may need to be redeployed to manage adult patients during periods of increased demand. We recommend that any staff redeployment be supported with appropriate training and education. This should only occur if there are sufficient resources within the PICU workforce to manage essential services (e.g. paediatric trauma, burns, organ transplant and urgent surgery) in addition to the emergency admission of COVID-19 and non-COVID-19 infants and children. It should take place as part of a system-wide plan to manage an overwhelming case load in adult facilities.
The principles of critical care outreach should have pre-emptive, proactive and reactive solutions to:
1. Identify patients who are unlikely to benefit from ICU treatment and guide appropriate goals of care discussions
2. Identify patients who need ICU as early as possible by:
a. Pre-emptive rounding and huddles between ward-based and ICU-staff
b. Modification of RRT calling criteria
3. Prevent In-Hospital Cardiac Arrest (IHCA) in COVID positive patients, as this is associated with an inhospital mortality > 90%.
Where possible, there should be a senior decision maker (senior registrar or consultant) from ICU available to assist in these processes.
ANZICS supports the recommendations of the International Society for Rapid Response Systems (iSRRS). Modifications to rapid response team (RRT) models of care should align with these guidelines whilst being individualised to the needs and resources of each jurisdiction.
In order to minimise the risk of healthcare staff infection, we recommend that:
In order to reduce the demands on ICU staff and facilitate optimal patient management and disposition, we recommend that:
In principle, the movement of patients with COVID-19 should be limited with all efforts made to ensure the patient is initially admitted to the appropriate location and only necessary investigations are performed outside the ICU. Staff safety is paramount and all staff involved in transferring a patient with suspected or proven COVID-19 infection must be proficient in the use of PPE and infection control procedures.
Once a patient is admitted to the ICU, transport outside of the ICU should be limited. If transport is required, then coordination at a senior level is mandatory to ensure safety standards are maintained.
We recommend the following for intra-hospital patient transport:
Capacity for inter-hospital transport is likely to be limited and may significantly impact access to critical care for regional Australian and New Zealand patients. Redistribution of patients as part of a load rebalancing strategy to address health areas under strain will involve patient transport services (both aeromedical and
road). We strongly support efforts to increase the capacity of these services.
A balance needs to be made between having patients treated at a centre with greater resources and overwhelming patient transport services with high numbers of low acuity transfers. Transferring patients later in their clinical course may necessitate intubation for patient and staff safety or logistical reasons as higher levels of oxygen flows via mask or nasal prongs may exhaust oxygen supplies.
We recommend a means of central coordination for inter-hospital transfers utilising senior clinicians in later stages of the pandemic (red and black). This should leverage off existing governance structures and incorporate clear lines of communication, balancing individual clinical need, against local and system-wide resources. This will allow treating clinicians to focus on clinical care.
ANZICS recommends that ICUs co-ordinate with EDs to support the management and disposition ofcritically ill patients during periods of high COVID-19 patient load.
Inter-departmental plans should include the early referral to ICU of patients (both COVID-19 and non-COVID-19) requiring physiological support as a means to optimise patient flow and improve emergency department capacity.
We support the Australian College of Emergency Medicine COVID-19 guidelines and recommend they be considered in the development of local policies.
Metrics and data monitoring are central to the provision of a safe and high-quality healthcare system. They are an essential component of the NSQHS Clinical Governance Standard (Standard 1 Action 1.08 and 1.09), which aims to ensure the implementation of a framework within health service organisations that maintains and improves the safety and quality of health care.
We recommend that metrics and data monitoring take place within the framework of a programme with clear and achievable goals and practical steps for implementation. Metrics in themselves, outside of a plan of action, are without meaningful value. The principles of data security and structured governance processes around the collection, storage and reporting of data are the same during the pandemic as they are at other times.
ANZICS recognises that the collection of relevant and accurate data is required to provide visibility of activity and resources of a health care system and the intensive care services within that health system. The secondary purpose of this data is to provide a basis for health policy development, future health service and intensive care planning and research.
We recommend that:
The development and application of meaningful metrics will require human, financial and computational resources. ANZICS recommends that data collection systems should be integrated into the health care system and have longevity. We recommend that data collection should be performed and overseen by dedicated staff who are funded and trained specifically for this role. We recommend delivery of care to all critically ill patients is monitored and a well-established reporting system is in place, so that analysed data can be interpreted and findings can be actioned by relevant bodies/authorities.