Version: 1 Page 1 of 12 1. Title ICU Contingency Plan for Mass Casualty Disaster and Major Infection Outbreak 2. Executive Summary 2.1 The Coordinating Committee in Intensive Care [COC(ICU)], with its members comprising of the ICU directors and ICU nurse head representatives, serves the role to provide the professional viewpoints on the preparation of the contingency plan for critical care surge capacity, which are outlined in the following. 2.2 The plan has summarized the discussion in the ICU Strategic Workshop held in 13 December 2007 and discussion in several COC (ICU) meetings held between 2005 to 2007, and is developed in line with the principles of emergency response from the synthesis of information obtained from: i) Emergency response plans of various developed countries; ii) HA Response Plan for Major Incident; iii) HA Contingency Plan for Influenza Pandemic; iv) HA ICU Contingency Plan for Human Swine Influenza (HSI) / Influenza A (H 1 N 1 ); and, v) HA AOM papers listed in the SARS review reports follow-up. 2.3 The plan has covered the possible measures to manage the emergency mass critical care events in both mass casualty disaster and pandemic outbreak, including: i) stated clear governance and command structure in the crisis, and the coordination between HA Emergency Executive Committee (EEC), HA Central Command Committee (CCC) and Clusters ; ii) using a staged approach to augment ICU surge capacity, iii) considering postpone of non-emergency and non-urgent clinical services to concentrate the staff and resources on the most seriously ill patients if necessary, and iv) providing just-in-time training to expand the pool of emergency workforce. 2.4 HA has prepared to increase the critical care capacity for the possible emergency mass critical care events by nearly 50%. For the isolation beds for critical care patients, the capacity can be surged by 180% in maximum. The robust plan to increase the number of ICU beds in three stages is developed with the agreement of the ICU directors and Cluster Chief Executives and reflects the hard work and dedication of many doctors and nurses in the hospitals.
Version: 1 Page 2 of 12 2.5 In order to achieve this very significant increase, HA has the deployment list of reserve medical and physiotherapy staff for ICU emergency. Just-in-time training on the nursing staffs would also be considered if significant increase in the demand of ICU nurses is expected. 2.6 The plan has also covered the coordination of ICU beds for both adult and paediatric critically ill patients. It is determined that paediatric critically ill patients should be appropriately cared for in adult ICU with the support from the paediatric team, with the limitation in increasing the number of PICU beds. 2.7 The role of Head Office Duty Officer (HODO) and Head Office Major Incident Control Centre (HAHO MICC) to liaise with the Medical Control Officer, hospital A&E, Cluster/ Hospital MICC Coordinators and other Government agencies (including the ambulance service for transportation of ICU infectious case) in appropriate diversions of patients to hospitals is also included in the plan. 2.8 On top of the above, HA has also prepared separate auxiliary plans in hand hygiene, vaccination, antiviral medication, isolation policy, etc to control any pandemic outbreak, thereby minimizing pressure on the hospital services, particularly the ICU service; and ultimately to help people stay healthy. 3. Objective of the plan 3.1 It is expected that in a mass casualty disaster or during major infection outbreak there is need to surge the ICU capacity for the management of the critically ill patients. However, the surge of ICU capacity is less flexible than the surge of general ward services because of the requirement of special bed setting, bed spacing, trained staff and highly technological equipments for the provision of ICU services. 3.2 Also, because of the difference in the setting and the level of service provision in individual ICUs, not all ICUs can offer critical care surge capacity goal in a short period of time without a prior concrete planning. 3.3 This plan thus outlines the major considerations and provides the guidelines for the ICU and hospital management who are charged with preparing for the surge of ICU capacity.
Version: 1 Page 3 of 12 4. Command Structure 4.1 The command structure for this plan is in line with the HA Response Plan for Major Incident and HA Contingency Plan for Influenza Pandemic. 4.2 When there is a Tier 2 or above civil disaster, or a S2 or above level infection outbreak, the HA Head Office Major Incident Command Centre (HAHO MICC) manned by the Department of Infection, Emergency and Contingency (IEC), HAHO will be activated by the Director of Quality and Safety Division, HAHO [D (Q&S)], the Chairman of the Central Committee on Infectious Disease and Emergency Response (CCIDER). 4.3 Upon notification by the D (Q&S) of the plausible disaster, the HA Chief Executive (CE) will consider to convene a Central Command Committee (CCC) with involvement of the Directors, CCEs and the necessary expertise; and an Emergency Executive Committee (EEC) under the HA Board will be called into action. 4.4 The CCC will effect major central policy direction in HA; and the CE, as the field commander-in-chief, would be the ultimate person to be held responsible for the final decision on mobilizing HA resources and manpower for management of the crisis having taken account of the advice of the EEC. 4.5 The Governance Structure is in place in response to the Human Swine Influenza (HSI) outbreak in year 2009 and its details are attached in Appendix I as a reference. Under such structure, the Cluster Chief Executives, or their delegates, take the lead to internalize emergency response and execute the relevant contingency measures in individual cluster, which include the measurements related to ICU services. 4.6 Upon requested by the HAHO MICC, the Cluster MICC should be activated to act as the communication hub between different clinical units in the cluster, and maintain close communication with HAHO MICC during the crisis.
Version: 1 Page 4 of 12 5. ICU Bed Mobilization General principles 5.1.1 The major difference of the ICU bed mobilization among mass casualty disaster and major infection outbreak is that the number of extra ICU beds required can be estimated in the former but is uncertain in the latter case. 5.1.2 In a mass casualty disaster the surge of ICU capacity is required in the first few hours to the first few days after the disaster and the time for preparing the surge ICU capacity is very limited. On the contrary, the impact of the major infection outbreak can last for weeks or months; but the time for preparing the surge ICU capacity may be more and could even be divided into stages. 5.1.3 The vast majority of the mass casualty events do not generate overwhelming numbers (hundreds or thousands) of critically ill victims, but in responding to a major infection outbreak the availability of the existing ICU isolation facilities may not be adequate to cater for the service need. 5.1.4 Although there are clear guidelines and protocols on the inter-hospital transfer of critically ill patients, with the consideration of patient safety and the manpower required for patient escorts, it is not recommended to have a large number of such transfers in the mass casualty events. 5.1.5 Rather, the early appropriate triage of patients will be more important to ensure the provision of essential ICU services to help the greatest number of people survive the crisis. The Head Office Duty Officer (HODO) will liaise with the Medical Control Officer, hospital A&E, Cluster/ Hospital MICC Coordinators and other Government agencies to ensure that the right patient is in the right bed at the right time.
Version: 1 Page 5 of 12 5.2 ICU Bed Mobilization for Mass Casualty Disaster ICU Space 5.2.1 Should a sudden event overwhelm the existing ICU resources, due to the sudden nature of the event there is insufficient time to decant patients or effectively augment the response in a timely manner, reactive mass critical care strategies may be employed to buy time for the resource allocation, patient redistribution and use of alternative care sites to accommodate the ICU patients. 5.2.2 Hospital top management should determine converting alternative care sites into temporary ICU for case diversion. Based on the local ICU expert assessment, the less severely ill existing ICU patients from the major ICU, and those casualties required basic ICU care should be transferred to the temporary ICU so as to vacant the major ICU for the most critically ill casualties. 5.2.3 The alternative care sites which can be taken into consideration include the O room or E-ward in the A&E department, the recovery room, the CCU and the ventilator ward. Staff 5.2.4 If the existing manpower cannot cover the surge in the ICU service, the usual ICU staffing should then be modified to include doctors and nurses deployed from other clinical areas. Corresponding reduction of non-emergency, non-urgent specialty services in the hospitals/ clusters would be activated upon the notification from the CCC. 5.2.5 The nurses currently not working in ICU but with i) previous ICU working experience; ii) formal ICU training; or even, iii) basic ICU training; should be deployed from the other clinical departments according to the hospital/cluster deployment list. 5.2.6 The number of the deployed nurses should be adequate to maintain the current ICU nurse: bed ratio at 4.2:1 in the ICU or at 2.1:1 in the temporary ICU. The least ratio of ICU nurses to deployed nurses should be maintained at 1:2. There should be clear job delineation between the ICU and deployed nurses. For instance, the ICU nurses can take up the role of advisor to guide the deployed nurse on critical care
Version: 1 Page 6 of 12 issue such as vasoactive agents and sedation administration, while the deployed nurses have the primary responsibility for patient assessment, administration of medications and general bedside care. 5.2.7 The just-in-time training for nurses should also be considered if the demand on extra nursing manpower is expected to be outweighed the number of staff in the deployment list. Details will be mentioned in point 7. 5.2.8 Similarly, deployment of medical staff from other departments can involve i) those with prior working experience in ICU; ii) those working in ICU as part of the training requirement; and, iii) volunteer. 5.2.9 Doctors currently not working in ICU but with the following qualification should take up the role as ICU doctors: i) doctor with fellowship status in CCM or ICM; ii) doctor with >1.5 years of active core training in CCM/ICM; or, iii) doctor with specialist status in other specialty plus 1 year of active core training in CCM/ICM. 5.2.10 Medical staffs without the qualification listed in point 5.2.8 should be classified as non-icu doctors. The ICU doctor: non-icu doctor: patient ratio, taking reference to the suggestions from the Task Force for Mass Critical Care Summit, should be 1:4:24. 5.2.11 If the manpower and care facilities in a hospital or cluster are used up to accommodate the further surge of ICU patients, the senior HODO will coordinate inter-hospital transfer of the remaining critically ill casualties based on the expert input from the Chairmen of the COC (ICU) and the Directors of the ICUs involved. 5.2.12 Cluster should annually update the Head Office Nursing Services Department the nursing deployment list in point 5.2.5. 5.2.13 List of reserved doctors from other specialties suitable for mobilization into respective ICU should be prepared by individual ICU Heads and kept the HO IEC department updated of it annually.
Version: 1 Page 7 of 12 Modifying usual standards of care 5.2.14 To ensure the availability and efficiency of essential ICU interventions, ICU should consider giving priority to interventions that fulfill the following criteria: 1) interventions that have shown or are deemed by critical care expert best professional judgment to improve survival, and without which death is likely; 2) interventions that do not require extraordinarily expensive equipment; and 3) interventions that can be implemented without consuming extensive staff or hospital resources. 5.2.15 From point 5.2.14, ICUs should plan to be able to deliver the following during a mass casualty disaster: basic mode(s) of mechanical ventilation, haemodynamic support, antibiotics or other disease-specific countermeasure therapy, and a small set of prophylactic interventions that are recognized to reduce the serious adverse consequences of critical illness. For instance, i) maintaining the head of a mechanically ventilated patient s bed at a 45 angle to prevent ventilator-associated pneumonia, and ii) thromboembolism prophylaxis. 5.3 ICU Bed Mobilization for Major Infection Outbreak ICU Space 5.3.1 In the early phase of the major infection outbreak, e.g. SARS or Avian Influenza, the suspected and confirmed infectious ICU cases should not be cared in a cohort area to prevent the spread of disease but rather be isolated in Cat B level or above isolation rooms. Therefore it is not recommended to cohort the existing ICU as a dirty ICU in the early phase of outbreak. 5.3.2 From point 5.3.1 and assuming 100% of the infectious cases required ICU care, each cluster should have stocktaking of the isolation beds in individual ICU, as the preparation to admit the first log of infectious patients in the early phase. This has been done in the 2009 HSI outbreak and the details are spelled out in the HA ICU Contingency Plan for Human Swine Influenza (HSI) / Influenza A (H 1 N 1 ). 5.3.3 With the progress of the pandemic, if the ICU isolation beds are fully occupied, depending on the infectiousness of the disease, either the isolation facilities or other clinical area outside the ICU are converted to outreach ICU; or cohort the normal ICU as dirty ICU to accommodate the additional ICU patients.
Version: 1 Page 8 of 12 5.3.4 The surge of ICU isolation beds in point 5.3.3 will be divided in three stages and the triggering point of each stage is also spelled out in the HA ICU Contingency Plan for Human Swine Influenza (HSI) / Influenza A (H 1 N 1 ). 5.3.5 The outreach ICU should be equipped to serve as ICU with additional service panels (i.e. the oxygen and compressed air sockets, suction port, essential electric power sockets, etc). 5.3.6 If the disease is not confirmed non-airborne precaution by both the WHO and the CCIDER, only the clinical area equipped with negative pressure ventilation, 6 to 12 cycle per hour air-change, and appropriate discharge of air outlet facilities can be cohort as a dirty ICU. 5.3.7 With the considerations of infection control and OSH issues, cases admitted to the cohort dirty ICU should be those confirmed infectious cases required mechanical ventilation and the cases should be ventilated with the ventilators having the built-in scavenging system. For those non-intubated critical patients who are on high flow O 2 or non-invasive positive pressure, they should be isolated. 5.3.8 Certain number of ICU beds will be kept to span usual ICU service need for the other non-infectious ICU cases. However the normal ICU service provision will be largely scaled down according to the number of dirty ICU beds required. Intra or even inter-cluster transfer of ICU patients is necessary to allocate the patients to the hospital with the most appropriate ICU facilities catered for the patient need. The senior HODO in the HAHO MICC will monitor the ICU bed and isolation bed occupancy by using the Patient Administration System (PAS), and coordinate inter-hospital transfer of ICU patients based on the expert input about the clinical acuity of patients, and the need for resource-intensive procedures and specialized care from the Chairmen of the COC (ICU) and the Directors of the ICUs involved. Staff 5.3.9 The principles listed in point 5.2.4 to 5.2.13 are also valid for the major infection outbreak; however, depending on the infectiousness of the disease, there may be markedly fluctuation of manpower available, more planned reserve manpower may be required when taking the OSH issue into account. From the SARS experience, it is highly recommended to grant the staff longer tea break after they have full-geared
Version: 1 Page 9 of 12 with PPE for certain hours in a working shift, and extra day off in every two week work to ensure that they have adequate rest. Modifying usual standards of care 5.3.10 The principles listed in point 5.2.14 to 5.2.15 are also valid for the major infection outbreak. However, as mentioned in point 4.1.1, the number of patients required ICU care during a major infection outbreak is quite uncertain. To prepare for the worst, if all the above means to increase ICU capacity are exhausted, the COC (ICU) should assess the approximate risk to their patients and transmitted the assessment to the hospital leadership and the CCC through the line of communication delineated by the CCIDER that the least ICU service provision has reached its limit. 5.3.11 The operation mode of ICU at that time will be subjected to reframed. One possible way is that the ICU staff will be deployed to assist other clinical areas to provide the life saving support for the patients, such as the basic airway management and haemodynamic support. 6. Special concern: Paediatric ICU services 6.1 The isolation facilities in the existing PICU are very limited and it is expected that during a major pandemic outbreak the infected PICU cases may require admission to the adult ICU. 6.2 However, most of the adult ICU staff, including both medical and nursing staffs, are not appropriately trained and specialised in caring the PICU patients. 6.3 It is agreed that every cluster should have its CCE delegated coordinator to look after this issue and make the relevant arrangement in supporting the PICU service by the AICU. In general, if the AICU admits the PICU cases, the paediatric team should deploy their PICU and other paediatric ward staff to the AICU and take the lead in the caring of those PICU patients. Staff in AICU will change their roles to be the assistances.
Version: 1 Page 10 of 12 7. ICU Staff training 7.1 The surge of ICU capacity is very much depended on the number of staff available, especially the nursing staff, to man those extra ICU beds. 7.2 From the past experience of major incidents like Pat Sin Leng Fire, Garley Building Fire and SARS, cross-hospital ICU staff deployment was ineffective in meeting the service needs of the surge ICU capacity. 7.3 As the nurse training in ICU is much complex and sophisticated than those in other clinical areas, it takes weeks to train up a non-icu nurse to carry out ICU nursing care. The feedback from the post-sars short term ICU training provided to the nursing staff, the so-called ICU Prep course, has shown that such kind of training is discouraging to equip the nurses to work in ICU in the future outbreak. The Institute of Advanced Nursing Studies will work with the ICU Group to modify and devise another training course to meet the need. 7.4 Hospitals are recommended to arrange clinical attachment and on-site learning for non-icu nurses on a rotation basis as a preparation for the contingency. 7.5 The trained non-icu nurses should only be assigned to less complex ICU cases (for instance, cases with maximum two organ failure) and be partnered with the ICU staff when they are deployed to the ICU. 8. ICU Equipments 8.1 Stockpiling sophisticated and expensive ICU equipments to use solely during very high demand situations such as mass casualty events or major infection outbreaks is financially and logistically infeasible. 8.2 Individual ICU should monitor the utilization of the ventilators and ICU bedside monitors and alert the CCIDER through the COC (ICU) Chairmen to assess the need of urgent procurement or re-distribution of the above equipments. The CCC will consider coordinating the urgent supply of these equipments in the HO level if necessary.
Version: 1 Page 11 of 12 9. Conclusion Like the most developed countries, Hong Kong has significant limitation to provide timely and usual ICU service to a surge of critically ill victims. The COC (ICU) has tried to synthesize the information from different sources, with thorough consideration on our resources available, to provide this conceptual and operational framework to help avoiding crisis decision making. Nevertheless, optimization of disaster preparation depends on coordination at multiple levels.
Version: 1 Page 12 of 12 Reference Devereaux A, Christian M D, Dichter J R et al. Summary of Suggestions from the Task Force for Mass Critical Care Summit, January 26 & 27, 1007. Chest 2008; 133:1-7 Rubinson L, Nuzzo JB, Talmor DS et al. Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the Working Group on Emergency Mass Critical Care. Crit Care Med. 2005; 33(10):2393-403 Critical care strategy: Managing the H1N1 flu pandemic September 2009. National Health Service, Department of Health, UK. The ANZIC Influenza Investigators. Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand. NEJM 2009; 361 (20):1925-1934 Hota S, Fried E, Burry L et al. Preparing your intensive care unit for the second wave of H1N1 and future surges. Crit Care Med 2010; 38(3): S1-S10 Toner E, Waldhorn R, Maldin B et al. Hospital Preparedness for Pandemic Influenza. Biosecurity and Bioterrorism 2006; 4(2): 207-217 Roccaforte J D and Cushman J G. Disaster preparation and management for the intensive care unit. Curr Opin Crit Care 2002; 8:607-615 Response Plan for Major Incident, July 2005. Hospital Authority, HKSAR. HA Civil Disaster Contingency Plan, revised September 2007. Hospital Authority, HKSAR. HA ICU Contingency Plan for Human Swine Influenza (HSI) / Influenza A (H 1 N 1 ) 2009. Hospital Authority, HKSAR. HA Contingency Plan for Influenza Pandemic, 1 July 2006. Hospital Authority, HKSAR. SARS Review Reports follow up, 3 October 2009. Hospital Authority, HKSAR.