Cross-skill training for pandemic COVID-19

17 March 2020

Introduction

The UK government has introduced (16 March 2020) increasing measures to prevent the escalation of cases of pandemic COVID-19 infection within the UK.  It is likely to represent one of the greatest public health and critical care emergencies in our lifetimes, with predicted numbers of patient requiring critical care increasing over the next 4–12 weeks.  It is generally accepted that increased critical care capacity will be required over this period.  Staff from out-with critical care may be required to help care for these patients.  This document summarises an approach to the training of non-ICU members of staff with transferable and/or trainable/retrainable skills to facilitate safe and effective care of these patients at this time. 

The difficulty of working with different people, in a different environment, with different equipment, looking after different people in different dress (PPE) should not be underestimated.

 Principles

• Local adaptation of these guidelines will be required to suit local service and staff requirements. Examples of checklists and protocols from Sheffield and Portsmouth, national guidance from the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) and international guidance and training from the World Health Organization (WHO) are included at the end of this page.

• Increasingly staff may be required to work out-with their ‘comfort zone’.  Sufficient supervision and support will be required to allow for safe care at this time, especially for doctors in training.

• Local adaptation will need to be imaginative to suit local needs.

• Effective and visible management will be required (specialty reorganisation guidance available here).

• We must all look after each other (see wellbeing resources).

Personnel

• Although initially aimed at anaesthetists there will be others who can help with the management of the critically ill during the pandemic.

• In general the skillset that members of staff can bring to these patients and not their current job/grade/title should be reviewed.

• Previous critical care experience should be actively sought and used in critical care where possible.

• 2-or multiple way swaps may be required to optimise critical care delivery during this period (eg consultant surgeon helps on urology ward to allow core trainee with critical care experience to work on critical care).

• It may be that ‘pairs of hands’ (in PPE) are required rather than advanced skills.  Any suitably trained member of staff could be involved in these tasks such as assisting with proning patients, and clinical interventions, cannulations etc. But also (non PPE) activities in support of critically unwell patients, such as administration tasks/referrals/prescriptions etc. 

Teams

Separate guidance has been published by NHS England about service reorganisation for anaesthesia and critical care.

With increasing critical care demand it may be that mixed teams of anaesthetists/intensivists/surgeons/physicians work with nursing and AHP staff from a variety of backgrounds to care for patients in differing environments.  Local adaptation of teams will be required depending of local critical care and other service demands.  Additional support should be identified in advance of being required to assist with the delivery of critical care services.  Local surge protocols should be in place for this eventuality. 

It is suggested that staff work in teams with clear leadership and other allocated roles. These may include creating teams and areas for endotracheal intubation, line insertion, transfer for imaging and support for outreach services as well as general management of critical care patient (specialty reorganisation guidance available here).  It is important that there is appropriate oversight of care provision across the site and this should be in partnership with nursing and managerial staff.

Cross-skill training

Aim

To ensure that staff are sufficiently trained to work in teams looking after critically ill patients under the supervision of trained critical care doctors during the pandemic period.

Acknowledgment of pre-existing skills

 Many doctors have skills within their daily practise that will be required during the pandemic period:

• Practical: intubation, sedation, iv cannulation, arterial line and CVC insertion

• Medical: management of the critically ill, triage

• Communication: speaking to families and patients about their wishes, End of Life care.

Although the obvious group of doctors with both the practical, medical and communication skills are anaesthetists, there may be individuals who will be less familiar with some of these skills. There will also be doctors from other specialties who possess such skills and are able to provide support.  It is acknowledged that a number of doctors will have had these skills in the past but may not have used them for some time.  Refresher training as outlined on this page aims to address this issue.

Overview

 A short overview video of management of COVID-19, and general ICU principles for non-intensivists has been produced in Cambridge by Charlotte Summers

Training checklists

Local checklists should be developed to ensure that all staff have had enough training prior to involvement in care of the critically ill during the COVID-19 pandemic (the Sheffield Teaching Hospitals NHSFT is available here) 

Local specific training/induction

 This will need to be locally developed and delivered but should include:

• Orientation: location of equipment including emergency equipment, staff facilities

• Refresher of daily routine

• Documentation systems including e-systems

• Daily or other checklists and LocSSiPs already in place

• Equipment including but not limited to ventilators and infusion devices

• Medication regimes, unit sedation protocols.

An example from Sheffield is included here

ARDS specific training

It is anticipated from experience derived from both China and Italy that the majority of respiratory failure association with COVID-19 will be acute hypoxic respiratory failure akin to ARDS. Management of ARDS has been protocolised in many ICUs and an example is included here of the Portsmouth SOP.  FICM guidance on the management of patients with ARDS is here

COVID-19 specific guidance

Guidance on the management of COVID-19 has been produced by the World Health Organization in the form of a comprehensive e-learning package.  Abbreviated training can be found summarised here from Sheffield.  Other guidance in terms of wearing PPE has changed regularly and the NHSE/PHE and local trust guidance should be followed.  In summary: 

• PPE: should be worn for all aerosol generating procedures

• Early intubation. NIV/HFNO is associated with aerosol generation and has not been shown to demonstrate a clear advantage over early intubation in patient with COVID-19 related hypoxic respiratory failure

• No antiviral therapy has been shown to improve outcome

• Steroids are not indicated for the management of respiratory failure

• Prone ventilation may prove helpful but is logistically more difficult in full PPE. 

General intensive care housekeeping 

The use of FASTHUG or similar and/or daily checklists to ensure that routine care is not forgotten may not be familiar to all doctors working outside critical care.  Education on their use is included within the Sheffield COVID-19 guidance here 

Ethical and end-of-life decision making 

In the section on team working it is envisaged that critical care doctors will lead teams, but increasingly with increased demands other members of the team may have to discuss such issues with patients and families. End of Life decision making in critical care can be difficult. Advice and guidance from FICM is available here. Further guidance on decision making will follow this guidance. 

Wellbeing

Throughout this guidance the need for team working, patient and staff safety and staff wellbeing should not be underestimated. Staff who are unfamiliar with critical care may need to be supported in dealing with the death or a patient or the emotions of families in the face of the death of a loved one. Wellbeing support developed in Cardiff for the ICS can be accessed here 

References 

Overview video

• COVID-19: The ICU basics

Sheffield Teaching Hospitals NHSFT ICU developed content

• Daily review checklist

• ARDS in COVID-19 guide

• Training checklist

• Face-to face teaching session outline

Portsmouth Hospital NHS Trust ICU developed content

• Hypoxic respiratory failure guidance (not COVID-19 specific)

Faculty of Intensive Care Medicine guidance

• End of Life Care

• Guidelines on the Management of Acute Respiratory Distress Syndrome (ARDS)

World Health Organization (WHO)

• e-learning package on Severe Acute Respiratory Infection

Intensive Care Society

• Wellbeing resource library

Authors

Mark Carpenter, Helen Ellis, Kris Bauchmuller, with review and comment from Danielle Bryden, Ramani Moonesinghe, Matthew Williams, Chris Carey and Sarah Clarke.  Additional content kindly contributed by Nick Tarmey, Charlotte Summers, and adapted from work by Matt Morgan.