UKC

I have watched lots of footage of intensive care during the pandemic and something came to me that I thought was worth sharing to see if anyone on here could comment.
It looks like Intensive Care Units (ICUs) are set up to cover a wide range of potential conditions and thus include a broad spectrum of resources. The demands of a Covid ICU are more specific so might it be possible to set up a dedicated Covid ICU and release some resources for the wider treatment of people needing IC? This might allow non-Covid cases to be treated and reduce the total pressure on the NHS.
Am I deluded in this thought?

The shortage is not space or kit. It's nurses and other technicians.

who's going to staff it ?

i did wonder if they could use trained and supervised volunteers for the proning which seems to occupy tons of people. Sure the logistics are a nightmare and its been thought of etc etc

It’s a nice idea but it’s the staffing that’s the issue, from cleaners to consultants. 

Yes the 'proning - turning' of patients looks like an area that could be the basis of refinement. It looks like a low-skill, trainable yet precise activity that could be done by other people (who may need recruitment & training)  to free up higher trained technicians.

There is so much to nursing in general and even more to intensive care nursing, it’s difficult to get volunteers to do it.

A lot of it is not just knowledge but intuition gained by experience.

In all likelihood they’d make loads of mistakes which would be risky and probably waste time.

There are plenty of hospitals with effectively an ICU and a Covid ICU. The difficulty is staffing them, due to the numbers required and the amount of staff off sick, as others have said. Consultants in "non Covid treating" specialities are doing HCA shifts in some London hospitals. You're not going to get a surgeon wiping someone's a**e unless things are pretty dire.

Please don't get me wrong - I can see that good quality intensive care requires a core of people with a high level of skills - accompanied by intuition & experience. However can they be supported by a group of well-trained support staff that may be recruitable to free up their skills to be used on the wider Covid patients?

Low skill. I don't think so. There's a list as long as my arm of what could go wrong and what to do about it.

Unfortunately not. That was the initial idea of the Nightingales. The thought was that the patient's would be single organ failure simply requiring ventilation for a period. The reality is high levels of renal failure, need for drugs to support blood pressure, thromboses and so on. As such they will typically require the full range of ICU services. Also, all critically ill patients such as these develop other complications and need the full range of support services of the wider hospital.

As others have said, the limiting factor is highly skilled ICU nurses. Physical space and beds, ventilators and so on are not in short supply. Renal filtration fluid is, and is nationally rationed.

This paper gives an indication of the complexity and medical knowledge needed for proning patients https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03128-6

Considering what is going on I would have thought if it was that simple they would be doing it. 

I doubt there is a person on here that hasn't watched someone do something simple looking and thought "I can do that" 

I got quite an expensive bill from a plasterer fixing my mistakes when I thought that. 

Getting back to the original question, an intensive care bed will be set up with a pretty generic set of kit - a ventilator, lots of pumps for infusing strong medications and a monitor to display a large number of measurements of physiological parameters. You then might bring along additional kit to support things like kidney function. 

The shortage is actually space, kit and staff.

Intensive care beds need a lot more space than normal hospital beds because of the area needed to run a ventilator, many infusion pumps and potentially a machine for haemofiltration. Normal bed spaces simply do not have enough room and for staffing reasons it is impractical to have patients in side rooms / in smaller bays (each patient needs to always be under the eye of a trained member of staff, and if you only have say 4 beds in a bay, you end up needing proportionally more staff per patient). Having these patients be transferred to the Nightingales would be a logistical nightmare as you need a specialist ambulance and a trained doctor per transfer and, once there, you no longer have other medical specialities on site for support and advice.

Kit is also an issue - lots of intensive care units are currently using additional ventilators that had been sidelined / were designed for use in areas rather than intensive care. So many COVID patients have been needing haemofiltration that there was recently a shortage of renal dialysis fluid. This is not an exhaustive list of the kit problems by any means!!

Staffing is an issue too. The department that I work in has needed to increase its nurse staffing by 70% and its junior doctor staffing by 50%. Consultants have also been doing rostered night shifts as they were finding that they were unable to go home due to the number and acuity of unwell patients. Many of these shifts are being done as overtime by existing staff, but staff have been re-deployed (e.g. from operating theatres) too. I notice that proning has been mentioned above - we are planning to have a proning team made up of surgeons to help with this, but proning/supining patients has a tendency to cause them to become unstable. An anaesthetist and trained critical care staff are definitely required to protect the patient's airway during proning and reduce the chance of harm to the patient.

I hope this gives you some idea of the issues involved.

Thanks for taking the time to make that detailed post, it deserves a wider audience. 

.....I notice that proning has been mentioned above - we are planning to have a proning team made up of surgeons to help with this....

Thank God the orthopods can finally display their finely honed biceps!

Thank you. Must be an awful situation to work in, you have my gratitude

Can't tell if the OP is sarcastic or not... So I'll respond as if it was:

It's a great idea. We could build them in all the conference centres we're not using. They could even name them after some historical figure famous for service to healthcare......

Still wouldn't have any more doctors/nurses to staff them though.

In Cyprus they have done pretty much what you suggest.  Don't know to what degree they're staffed by trained ICU nurses, although my wife (who is a trained ICU nurse, and has worked over here for more than 15 years in that role (and still is)) doesn't believe they are.  Whether that's so or not, the country has quite a low C19 death rate.  Make of this what you will.

thanks for that, interesting conclusions, suggesting being used at some places

This innovative management allowed three major benefits: (i) critical relief of permanent intensive care team’s workload; (ii) reduction of the nurse-to-patient ratio, permitting also the reassignment of critical care nurses to newly created ICUs; and (iii) devoid of any self-censorship for fear of overwork and burn-out, intensivist physicians were able to strictly follow PP guideline recommendations, ensuring the best standard of care for ARDS patients.

In Wales they've advertised bank shifts on ICU to paramedics and advertised for anyone (including med students, student nurses, HCA etc) with experience of proning patients to come forward to cover shifts.

But obviously a lot of these people are already busy with their own role elsewhere.

I would have thought it would be better to up skill experienced nurses/HCA from elsewhere in the NHS to cover ICU and use lesser qualified and rapidly trained staff elsewhere. Which i think is what a lot of NHS trust have attempted to do already.

My original post was serious not sarcastic. I watched several news items that showed the current state of many hospitals and I wondered if there were different ways of organising the precious resources of the skilled pepople by freeing them of less skilled but time-consuming tasks.
From the responses to my post I have learned that there probably aren't many opportunities to improve the processes and that having more fully trained & skilled staff is most likely the only way to cope with the problem.
Sometimes having someone who knows little about a subject can ask naive questions that prompt new thoughts amongst those that are deeply involved in a problem. That is what I was trying to do.
For those who responded - thank you and if you are working within the NHS I thank you even more for what you are currently doing to get us through this pandemic.

Thanks for this response to my OP, the linked report seems to indicate that creative approaches to the use of resources are being investigated in some hospitals.

If you watch Clive Myrie's reports from the Royal London, you will get an idea of the degree to which wards have been turned over to covid care, and the different levels of care provided, including sending patients out to specialist treatment centres (e.g. Papworth if they have space...). 12 out of 15 floors of the RL have covid patients. ICU capacity has increased from 40 to 140. Staff from all disciplines are helping in these expanded ICU services.

https://www.bbc.co.uk/news/av/health-55724994

You see your questions/assumptions as naive but they could easily be interpreted as insulting or disrespectful, even if unintentionally.

I don't think you, and many others, quite grasps the complexity of a modern ICU.

As a student paramedic on my theatre placement I watch a man walk into the anaesthetic room for a complex operation to remove his larynx and all associated lymph nodes. Over the course of the next hour or so the anaesthetist took this walking talking man and rendered him an ICU patient. Central lines, syringe drivers, infusion pumps, intubation, sats probe, capnography, ECG monitoring, urinary catheter, nasal gastric feeding tube, oesophageal temperature probe, bear Hugger blanket, arterial lines, internal blood pressure and blood gas monitoring etc etc. It was a humbling thing to witness.

Even as an experienced paramedic it is daunting transferring ICU patients, moving equipment around and risking accidently disconnecting a machine or dislodging something in that patient that they are totally reliant on for their existence, and worse still maybe not even realising. 

Add to that that most covid ICU patients are now conscious and it adds another level of complexity.

ICU staff need to understand and be proficient in what they are doing. Rapidly training people up to that from nothing really isn't an option.