Article Checklist Proformas to Guide and Document the Assessment of ...
Excess deaths occur when the capacity to deliver critical care to patients with Covid-19 is exceeded (i.e. those who require organ support do not receive it). This is happening around the world now. The media has sensationalised discussions on numbers of ventilators and the availability of ICU beds. Unfortunately, the capacity to deliver healthcare is in fact most limited by human resources. Furthermore those healthcare professionals on the frontline are at greatest risk of contracting the virus.
To improve patient outcomes during the ongoing Covid-19 pandemic; the capacity of healthcare systems to prevent, detect and treat acute respiratory illnesses must be increased. This requires an increase in the number of staff who can do this. The fundamental question is: how can this be achieved now?
Online educational materials have been developed to train healthcare professionals in the basic principles of intensive care. However, this does not help people at the bedside faced with a crashing patient. I believe that familiarisation of staff with the use of systematic checklist proformas for the assessment of critically ill patients (see review above) can increase the capacity of healthcare systems to deliver critical care.
Does anyone have any other ideas? Please share them.
Thank you.
There are some excellent online resources that can provide healthcare professionals with some basic knowledge of critical care.
Please share with anyone you think would benefit:
Pandemic education resource for non-ICU clinicians.
At the University of Toronto (and partner institutes) we have developed educational materials for non-intensive care clinicians who may well end up covering the intensive care unit during the pandemic. Quick ICU Training provides a study guide and quick reference resource for those upskilling, renewing, or reviewing their critical care capabilities in response to COVID-19. It is meant to support simulation- and practice- based learning and more formal online curricula.
The website is to be found at
www.quickicutraining.com
and there you will find the following resources-
Educational materials filled under a A,B,C system
Short narrated power points
Longer PowerPoint presentations
Cheat sheets and one page summaries
Triage guidelines
Other pandemic related resources
The site will continue to be developed with time as we get more materials and refine the current materials. We would greatly appreciate your feedback through the website.
A similar course has been developed by the US Society of Critical Care Medicine, titled “Critical Care for the Non-ICU Clinician”.
http://covid19.sccm.org/nonicu.htm
Greetings
It is a very apt question in the present scenario of COVID-19 pandemic. I believe you already have answers; short term training course and educational material followed by workshop-based training can help. Further, those staffs who have work experiences in caring cardio-respiratory patients in non-ICU set-ups and also working in emergency care can be the target for training. They can be identified as a pool, provided with materials (as described well by you in the above answers) and trained for basic procedures, trouble-shooting by designated mentors. Such a course do exist, e.g. Fundamental Critical Care Support (FCCS) https://www.sccm.org/Fundamentals/Fundamental-Critical-Care-Support
I shall be happy to know your strategies...
Dear Janet Lane
Thank you for your suggestion. The challenge with intensive care is that it is very demanding physically and mentally. In the UK intensivists are generally dual trained in either anaesthesia and intensive care. Towards the end of their careers they feel unable to manage the strain of working in intensive care and move into the other specialty full time.The other problem is that retired people are in a high risk group for adverse outcomes from Covid-19 so it is not fair to put them into an environment where the risk of exposure is extremely high.
It is an extremely difficult problem.
Janet Lane
That is actually a great idea. Move around the workforce to the areas of greatest demand. That may help in places where there are pockets where there is a high prevalence of Covid-19.There are clearly issues as no one is allowing their healthcare professionals to leave. For example my leave has been blocked. I am not allowed to leave my current workplace to help elsewhere even though there are very very few cases where I am.
However it does feel like the calm before the storm. Covid is coming for all of us...
Janet Lane
Thank you for this suggestion. I am sorry to seem pessimistic however nursing and doctors require hands on training. All the potential trainers are fully engaged with treating patients.When healthcare workers with limited training are faced with a crashing patient they freeze. They can not use what has been learned in lectures or online. This is why I advocate use of checklists at the bedside as cognitive aids to allow these healthcare professionals to function in a critical emergency situation.
How was this done during world war two? How do emerging economies cope with the need to train qualified staff in a short time and with limited resources?
Are there military short courses for this type of activity? (e.g. NATO). Would an approach like Nancy Caroline’s “Emergency Care in the Streets” help?
Thank you for your response Hans-Ulrich Iselin
I will look into these options.
The concept of Intensive therapy units were born after the 1952 polio outbreak in Denmark. Then, as now, the hospitals were overwhelmed with patients developing respiratory failure.
Prior to this, treatment had involved negative pressure ventilation, but these ventilators were in short supply. However an astute anaesthetist (Bjørn Aage Ibsen) instituted positive pressure ventilation via tracheal intubation, and enlisted medical students to manually ventilate the patients lungs. Patients were managed in 3 special wards, which aided charting and other management. Thus intensive care units were born.
There are several short face-to-face and online courses available. However when healthcare professionals with limited training are faced with a deteriorating patient they freeze. They can not use what has been learned in lectures or online. This is why I advocate use of checklists at the bedside as cognitive aids to allow these healthcare professionals to function in a critical emergency situation.
Paramedics are being utilised in many non-emergency roles in this crisis. Look to your local EMS and student EMS for roles.
Sonja Maria many thanks for your input. That is interesting. Paramedics certainly have the right skill set to manage critically ill patients. I will look into it.
However I am concerned that paramedics are also very busy running the ambulance services. There are reports that many people are not able to get to hospital. The lockdown is preventing people from supporting elderly relatives. Pulling paramedics from their primary role could be like robbing Peter to pay Paul.
Many of our services within Australia and New Zealand are looking at using 3rd year students for additional support roles during this time. Hospitals are doing the same. Its a win win situation for all. It would be beneficial to make some enquiries to see whats being done in your area. You may find opportunities.
Sonja Maria Many thanks for the great idea. It may be helpful. Medical students are certainly being involved in the effort.
Thank you
Jes Jose Many thanks for your recommendations. I agree that better use of critical care resources is required. In some places there is no longer a non-Covid ICU...everyone has Covid
Well-planned online courses, provided by multidisciplinary and experienced teams from highly efficient ICUs where large numbers of Covid-19 patients have been attended in the past months would do the job.
Such courses should de supervised by a consensus panel from prestige medical schools with a long career in delivering online courses, which should include interactive activities, videos in action, basic theory, and practical, challenging clinical case presentations. The coordination of these courses should de performed by the WHO, the CDC, and other recognized health agencies.
These type of multidisciplinary courses, involving different health care experienced centers would yield clinical health care guidelines for complicated Covid-19 patients.
Alejandro Rodriguez-Garcia Thank you for this suggestion. I am sorry to seem pessimistic however nursing and doctors require hands on training. All the potential trainers are fully engaged with treating patients.
When healthcare workers with limited training are faced with a crashing patient they freeze. They can not use what has been learned in lectures or online. This is why I advocate use of checklists at the bedside as cognitive aids to allow these healthcare professionals to function in a critical emergency situation.
I totally agree, but at least they have the background and the basics. The rest, they will have to learn to the bedside, and with the aid of a checklist that reminds them what they need to do.
Alejandro Rodriguez-Garcia totally agree. Many thanks for your contribution.
its require time, even a short couse of 3 month is enough for a ansesthist to cover icu
Shalendra Singh Thank you for your comment. I agree that anaesthetists are the specialists most most closely aligned to intensivists. In the UK many intensivists are also anaesthetists. Anaesthesia training already incorporates significant periods of training in critical care.
think all specialties (clinical and para-clinical) can chip into the framework, and not just leave it to the critical care team. This is the time to join hands and make a difference
Shalendra Singh Many thanks for your comment. I agree that it would be great for all specialties to support critical care at this time. The help can be direct and indirect. For example careful consideration of treatment escalation plans to refer those patient who may benefit most from critical care would be extremely helpful. This could reduce inappropriate referrals to intensivists and optimise use of resources.
It's urgency and can be done with short training. Necessity knows no law.
We have already seen in China and Italy: new recruitment and even the involvement of retired health workers.
We see the use of aircraft carrier in USA.
Muhammed Ashraful Alam many thanks for the suggestions. We certainly need to pull together every available resource that is available.
As per Indian a context, there is enough scope to train medical staff to meet the shortfalls. There are almost surplus staff of dental sciences graduate and technician's. These wel educated medical professionals already having enough trainings and can be further improved by short-term trainings. Similarly, other countries can adopt such individual's to serve covid19 pandemic.
Shalendra Singh many thanks for your suggestion. We did this months ago. Only Cancer, transplant and emergency surgery is proceeding. However your suggestion is extremely helpful as many centres may not have done this.