New Critical Care Guidelines for NSW Hospitals Detail ‘Ethical Challenges’ As System Pressure Continues

Critical care doctors, grappling with dozens of Covid patients in intensive care, have been given new guidance to prepare them for an onslaught of sick people.

New South Wales intensive care doctors have received new guidelines outlining the ‘ethical challenges’ they could face in the coming weeks if they were forced to limit life-saving ventilators to Covid-19 patients. who are most likely to survive ”.

The new guidelines prepared by NSW Health described life and death decisions that might emerge and guidelines for doctors on how to sort cases based on “likelihood of survival.”

To prepare for the onslaught, hospitals in NSW have suspended elective surgery with anesthesiologists undergoing emergency training to be sent to the Covid frontline.

Speaking on condition of anonymity to, a Sydney-based intensive care specialist said the new advice highlighted dark choices doctors could face.

“He says triage may need to be considered and if patients don’t you should speed up conversations at end of life,” he said.

“None of us want to get to this point, but it’s actually in the document.

“I guess the best analogy is what we do with organ transplants, because there are a limited number of organs and a lot more potential recipients. So we have organs, so we try to ensure that a scarce resource, in this case it would be intensive care, goes to the person who has the best chance of survival.

NSW’s official notice to intensive care physicians warns that a triage system may be needed in the coming months.

“During a pandemic, it will be important that consistent decisions are made regarding both ICU admission and continuing care when significant recovery is unlikely,” the official notice said.

“The ICU resource triage process includes both the resource allocation process and the resource withdrawal process, for all patients who may require intensive care during a respiratory pandemic.”

The term “withdrawal of resources” refers to removing Covid patients from ventilators if they are unlikely to survive to free a bed for a rescued patient.

“Complex ethical and clinical treatment issues can arise, it may be necessary at some point to begin prioritizing limited intensive care resources to those who need treatment and those who have the most chance. to survive, ”the council said.

“Such prioritization decisions should take into account the likelihood of survival of all patients, as well as the availability of limited critical care resources. “

Although NSW Premier Gladys Berejiklian predicted there was an ability to cope with the flare, the ICU doctor who spoke to said frontline health workers were concerned.

“If something keeps going up, without stopping, it’s going to overwhelm any system in the world. Queensland is looking into whether they can free up staff to send it, they don’t think it will go well in New South Wales, ”he said.

“If we have a push, we have a four step plan. The last step is like, you know, the whole intensive care unit that becomes a Covid intensive care unit, but that would be catastrophic because then we couldn’t do any of the other work. “

There are currently 150 patients in intensive care units in NSW. Of these patients, 127 are not vaccinated. There are over 900 Covid patients in the hospital.

The number of Covid patients on ventilators currently stands at 66 and the death toll from the current epidemic stands at 100.

As cases increase in NSW, data analysts predict cases could reach 3,000 per day or 20,000 per week by the end of September. But the real increase in intensive care is expected in October.

“There is a big gap between what is said publicly and what is already happening on the front lines,” said the ICU doctor.

“Because the reality is that the system is already not doing what it is supposed to do. We had to cancel a scheduled heart operation and other major surgeries for the patients. “

Regarding triage of patients, the ICU doctor said specialists are already talking about what happens when the hospital reaches its maximum capacity.

“New South Wales Minister of Health Brad Hazzard said we have quadrupled the capacity in intensive care. This is simply not correct. Most recently, he said we have quadrupled the number of fans. These two things are very different issues, ”he said.

“I’ve never seen one of those ‘quadruple fans’ on the front line. I am not sure if these surge fans are up to modern standards or not as I have never seen them.

“People are quite angry that you know their family members who are not vaccinated. There were two young people who died prematurely. The two surprised Covid to be family contact with a health worker. “

NSW’s Guidelines for Resource-Based Pandemic Decision-Making are designed to ensure that NSW’s intensive care services are supported to provide consistent care in a manner that is appropriate for current epidemiological and clinical conditions.

The guideline was developed by clinical experts and critical care ethicists in consultation with the NSW Covid-19 Critical Intelligence Unit (CIU) and the NSW Health Ethics Advisory Panel (HEAP).

Each hospital is invited to take an inventory of the following resources to inform their local emergency response in intensive care.
• Critical care beds available and additional ICU bed spaces not ordered.
• Potential suitable bed places in non-intensive care areas that can be used for intensive care
patients, p. ex. convalescence, perioperative units, respiratory units and intensive care units.
• Negative pressure isolation rooms.
• Non-pressurized isolation rooms.
• Check with engineering regarding air conditioning flow rates in negative pressure chambers and
single rooms.
• The equipment and consumables necessary to install and maintain a typical intensive care bed.
• Standard intensive care ventilators.
• Other ventilation devices including transport ventilators and those located outside the intensive care unit,
eg OT, emergency service (ED).
• Portable monitoring devices, including portable oxygen saturation monitors, inside the intensive care unit and other clinical areas.
• Availability of personal protective equipment (PPE).

About James K. Bonnette

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