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Appendix 13: Phased responses and staged triage for critical care
Further details on phased responses and staged triage for critical care are available. 71
Phased responses*
Phase 0
Normal activity
Phase 1
- Cancellation of all elective surgical procedures requiring post-operative critical care admission
- opening of 'closed' critical beds
- expansion of nursing capacity by increasing agency or 'bank' shift support.
- secondment of additional medical staff from 'elective' duties (eg anaesthesia) where necessary
- discharge of suitable patients to other ward areas (with appropriate upgrade in medical/nursing support for these areas)
- non-clinical transfer (if appropriate and capacity exists) to other critical care units
- maintenance of existing nurse: patient staffing ratios.
Admissions to Level 3 critical care beds according to Stage 1 triage response
Phase 2
As for Phase 1 plus:
- Upgrading of existing Level 2 beds to Level 3
- conversion of reserve critical care areas into Level 3 facilities (eg theatre recovery, HDU, SHCU, CCU)
- creation of Level 2 facilities in other clinical areas (if required)
- cancellation of annual leave for medical and nursing staff
- cancellation of all non-urgent surgery
- cohorting of index disease patients into specific clinical areas
- deployment of reserve-trained critical care nursing/medical staff.
Change in the ratios of critical care trained nurse:patient may be necessary; 1:1 ratio of nurse:patient target for all Level 3 patients, 1:2 for Level 2 patients
Admissions to Level 3 critical care beds according to Stage 2 triage response.
Critical care interventions according to Stage 2 triage response.
Phase 3
As for Phase 2 plus:
- Maximum use of all available Level 3 capacity
- nurse:patient ratios according to local Clinical Leads' discretion
- full recruitment of reserve-trained critical care nursing/medical staff.
Admission to Level 3 beds according to Stage 3 triage response
Critical Care interventions according to Stage 3 triage response
Phase 4
- An event of catastrophic severity could result in complete or partial collapse of some or all hospital infrastructures
- specific planning is not feasible given the extent of possible scenarios
- medical responses in such circumstances will be limited by the sustainability of personnel, equipment and environment
- it must be hoped that the process of planning for lesser phases will provide a basis for locally produced responses.
Staged triaging
Stage 0
Normal practice.
Stage 1
Stringent admission review for all patients referred. Level 3 care may be restricted on the basis of SOFA scale assessment or other identified clinically significant co-morbidities. Full medical and nursing supportive Level 2 care will be provided as appropriate, but cardiopulmonary resuscitation will not be attempted if this proves ineffective.
In Stage 1 triage it may be also necessary to introduce escalation limits on critical care interventions undertaken in patients; thus, in patients where Level 3 care has been initiated but physiological deterioration has continued despite full supportive care, it may be appropriate to consider limiting the degree or duration of circulatory support, or not to initiate renal replacement therapy if renal failure cannot be prevented.
Stage 2
The principles of triaging are similar to those of Stage 1, but greater stringency will be required in deciding which patients should receive Level 3 care and the extent of the treatment interventions provided. Such decisions should be shared by two or more consultants, both of whom, ideally, should be experienced in critical care medicine.
Stage 3
Even with maximally expanded critical care capacity it will only be possible to treat a limited proportion of the patients who may require Level 3 care as it is likely that all available Level 3 beds will be in use as a result of a progressively increasing referral rate. As a consequence, many potentially preventable deaths may be inevitable. New referrals will only be able to receive Level 3 care if a bed becomes available because a patient has died or recovered sufficiently to be discharged.
Staffing and equipment limitations will be such that critical care interventions will have to be restricted. Mechanical ventilation, fluid therapy (+/- vasopressor support), intravenous antibiotics and enteral nutritional support may be provided, but treatment will not be further escalated if deterioration occurs despite these interventions. In patients considered to be at risk of peptic ulceration, H2 receptor antagonist therapy may be considered appropriate.
The over-riding principle will be that only patients who are thought to have a good chance of survival with a reasonable life expectancy should receive Level 3 care. In patients who progress to multiple organ failure despite full supportive care, treatment interventions may have to be withdrawn, or non-escalation strategies agreed on the basis that other less sick patients are more likely to benefit from receiving Level 3 care. Use of the SOFA scale to assist in non-escalation/withdrawal decisions will ensure consistency for all patients.
The decision to withdraw or limit interventions earlier in the course of a patient's treatment than would be considered under normal circumstances is likely to cause distress to relatives and critical care staff, and the ability to continue functioning as a cohesive team will require careful attention to staff communication and morale.
As there is likely to be extreme distress, anger and even a risk of aggressive behaviour from family and friends of those in whom withdrawal of treatment interventions must be considered, it may be advisable to rely on non-escalation (eg not commencing vasopressor support or renal replacement) in many situations. Lack of availability of drugs, equipment or expertise may independently restrict such interventions.
Nursing and medical resources are likely to be under such pressure that the normal standards expected of critical care will inevitably be compromised and hence close teamwork and mutual staff support will be of crucial importance. Failure to preserve staff morale is likely to lead to increased absenteeism, and consequently increase staffing problems and reduce bed availability.
In the face of high demand there may be patients that the clinicians cannot differentiate between on the basis of benefit. At this stage allocation of ICU treatment may require to be by a random selection (lottery) process, taking into account the principles of the ethical framework ( Appendix 2).
Stage 4
An event which causes the collapse of some or all hospital infrastructures may render attempts to maintain a cohesive critical care response difficult or even impossible. It is unrealistic to plan provision of life-support interventions in the absence of adequate equipment, supplies, staff and a suitable environment. Under such circumstances the provision of intensive care must be regarded as a lower priority than more sustainable responses to preserve lives and reduce the suffering of the wider public.
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