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Tamas Szakmany

17 Oct, 9 tweets, 3 min read

@WCCTN

I see a lot of half-information and misrepresentation of figures on critical care capacity in Wales.
I was the @WCCTN clinical lead during the first wave so this is first hand info. #thread

In Wales, there are 189 funded and most importantly, staffed critical care beds. Not all can take ventilated patients, but even those can provide other organ support. It’s important as staffing requirements are different for mechanical ventilation and other forms of support.

At the start of the pandemic, we were asked to double the capacity like we would be asked for a natural or man made disaster. The UHBs identified physical resources for ~350 critical care beds, with various, mostly non-sophisticated ventilators attached to these.

In the badly hit areas we went over 250% capacity to look after #COVID19 and “normal” critically ill patients. We could do it as nurses and colleagues from other areas were drafted in to help. As the first wave died down, all that staff went back to work in their original roles.

They are the ones providing elective surgery, routine appointments, follow ups, clinics everything what we call “elective” activity. As this is unlikely to stop as it had in March/April, we will have no extra resources to draw on.

We have highlighted then, that critical CARE means people who can deliver high quality care, 1st and foremost, and NOT equipment/beds/ventilators. If we keep “normal services” running, as we should, we will not be in a position to provide the same high quality care on more beds

Ventilation (invasive or non-invasive) on 200 beds will be a challenge. Ventilation on 350 beds will be only possible if there is an acceptance, that complications will soar and lives otherwise saved could be lost. We have to look after patients with other critical illnesses.

The “increased critical care capacity” is myth, UNLESS there are means to appropriately staff those beds. Critical Care has always been about staff as highlighted in this recent non-COVID19 paper link.springer.com/article/10.100…

There are always trade offs. I don’t know what are the right answers to those trade offs. But it is important to know about them....

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More from @iamyourgasman

Tamas Szakmany

@iamyourgasman

19 Jun

I was walking the dog&while she was busy outrunning a doberman and a german shepherd puppy I was thinking about value for money and whether we, on the ICU, did some good in the economic sense during the #covid19 surge. I'm going off on a limb, so please feel free to correct me!

My health economics are very rudimentary, so anyone with a bit of knowledge will see the gaping holes. Please educate me :). The calculations are far from exact, mostly illustrative and rounded up or down so I could do maths easily in my head. This is what I came up with:

Our unit had 35 #COVID19 survivors out of 52 admissions. They were young, with average age of ~56 years. Let's assume that each survivor has 20 QUALY each = 700 QUALY. I then took a wild guess and said 1 QUALY after ICU is ~£20,000 as this is the NICE cutoff I remember.

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Tamas Szakmany

@iamyourgasman

17 Jun

The #medtwitter in the US has exploded with cynical and sometimes downright malicious voices after the #RECOVERYtrial announcement. I agree (as does the Trial steering committee based on the press release!) that policy change and implementation should only come after publication.

There are very important data omitted from the press release&the scientific community has every right to demand to see those in a peer-reviewed publication, which will certainly be dissected word-by-word. As a researcher leading this and other RCTs in my Health Board I'm biased.

I haven't seen the data as I'm only a contributor. What I'd like to highlight is the potential differences between UK and US healthcare and ICU in particular, to help understanding the numbers in the study.

Read 14 tweets

Tamas Szakmany

@iamyourgasman

10 May

The first wave of the #covid19 pandemic is subsiding and we are surfacing for a gulp of fresh air, before we dive in again. Some reflections on the ICU/NHS/research (thread)

We coped, just about. There wasn't a lot of wiggle room, but it sort of worked. We have been lucky, that not only the specialty, but also the wider hospital and NHS leadership listened to the warning sounds. Cancelling elective activity and freeing up acute capacity was key.

The quick planning and execution to go to surge capacity was one particular period where everyone involved should be really proud of. Doubling and trebling capacity was never needed in my patch before. The dusty plans only called for 2 weeks of it at most.

Read 17 tweets

Tamas Szakmany

@iamyourgasman

11 Apr

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.

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.

Read 13 tweets

Tamas Szakmany

@iamyourgasman

21 Mar

Some #medtwitter #CritCareControversies musings on #COVID19 after my first week. (Thread)
1. It’s a new disease. Normal ICU routines don’t seem to work. When you think they are ready to wean from the vent, they are not. Desaturation is common and deep.

2. They seem to like high PEEP as reported before. You can’t wean this fast as with a “normal” pneumonia. All this means light sedation doesn’t work and causes asynchrony. AKI is common and if caught early responds well to diuretics combo. Bloods are weirdly normal.

Still don’t understand what’s the best way to catch superinfection. CRP is up after day 2. We use PCT and it’s fine when sky high, but what about 2.0-3.0?? More data needed. Patients tolerate drying out without haemodynamic instability. Shock is not a prominent feature.

Read 12 tweets