Let's talk about "rationing" of intensive care in the context of #COVID19 (thread)
First of all, it's not happening in the UK. There are lots of misconceptions, which stem from the fact we are under enormous pressure.
First of all, it's not happening in the UK. There are lots of misconceptions, which stem from the fact we are under enormous pressure.
UK critical care has been and continues to be brilliant at making sure admission to critical care is offered to those who might benefit from it. After all, we have one of the smallest number of ICU beds in Western Europe, so we always had to choose.
There are established frameworks for this, taking into consideration the acute illness process, the chronic health and frailty of the patients and importantly, their views and values. Despite #COVID19 we still operate along these lines.
However, we don't operate "normal" intensive care anymore. By normal I mean what you can see in the BBC documentary filmed by @FRANK_FILMS_TV @LukePaveyUK in our hospital bbc.co.uk/iplayer/episod…
It's not normal to ventilate very unwell patients on anaesthetic machines and ventilators designed for home care, instead of high-tech ICU ventilators we like to use. It's not normal in the UK, that 2 ventilated patients are looked after by 1 critical care nurse.
It's not normal, that we have to expand our ICUs into areas we have never been before and that we have to think about O2 supply problems via the hospital pipes, we have to use drugs mixed in a single bag to save the number of pumps used or keep patients heavily sedated for safety
It's not normal that we have to use kidney machines for shorter runs so we can do "enough" on multiple patients to keep them safe, as opposed to treating them longer for the full benefit.
It's not normal, that the process of intensive care, which works by summarising small marginal gains is diluted and we start to see some of the hard-fought gains slipping away. It's not normal, that patients stay on the ICU for weeks: we go used to a length of stay around 3 days,
with small number of patients staying for longer (termed the long-stayers...) Patients with #COVID19 seem to need at least two weeks if not longer, creating a huge swell, which will lasts for months.
So while we still can offer a bed and a ventilator of some sort, we are not doing normal intensive care anymore. And we have to be clear that what we can give now is very different to what we could do a month ago. To maintain good outcomes, we have to ask difficult questions.
Is the person referred to us can still benefit from this not normal intensive care, with added risks and potentially diminished marginal gains? We knew for long that age and comorbidities are not on our side in this "game"
"Normal" critical care with adequate staffing, equipment etc actually looked at if admitting every elderly person for a trial of intensive care would improve outcomes and the results are very disappointing ncbi.nlm.nih.gov/pubmed/28973065 It appears our normal way of selecting pts works.
#COVID19 unmasked the chronic shortage of intensive care beds and facilities in the UK. As a result we have to ask the question: is this patient referred for critical care would really benefit? a lot more and a lot louder. In "normal" times more frequently the answer would be yes
