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Doctors call for guidance on how to prioritise critically ill patients in swine flu pandemic

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3092 (Published 29 July 2009) Cite this as: BMJ 2009;339:b3092
  1. Rebecca Coombes
  1. 1London

    “Extraordinary pressure” is expected on critical care beds this autumn, as the A/H1N1 influenza pandemic is set to enter a severe phase. However, the Department of Health has yet to clarify how it plans to meet demand, according to a House of Lords report this week.

    Peers also questioned whether clinicians felt confident about the legal consequences of making difficult triage decisions as the demand for critical care beds intensifies.

    The House of Lords Science and Technology Committee heard in May from the then health secretary, Alan Johnson, who confirmed that strategies would be introduced to boost intensive care capacity, including suspending elective procedures that need intensive care after operation. Ian Dalton, the national director of NHS Flu Resilience, the flu tsar, said that a doubling of critical care facilities would be possible “under a severe attack phase.”

    But Bruce Taylor, consultant in intensive care medicine at Portsmouth Hospitals NHS Trust, told the committee “with some force his concern about the provision for critical care in the event of a pandemic and also about the ethical guidance given to healthcare workers to assist them when presented with difficult choices arising from scarcity of intensive care unit resources.”

    According to the Department of Health, the worst case scenario is that 50% of the population need NHS treatment during the pandemic.

    Figures on 27 July from the World Health Organization show 816 confirmed deaths from swine flu cases globally. According to the Health Protection Agency on 23 July in England 840 patients have been admitted to hospital for swine flu, and 26 have died. GP consultation rates for flu-like illness rose sharply last week in England to 155 per 100 000 consulted, compared with 73.5 per 100 000 in the previous week.

    In their report issued this week the peers urged the health department to provide detailed information about critical care planning: “A pandemic could place extraordinary pressure on critical care capacity. In particular, we would welcome more detailed information about how it would be possible to double critical care facilities.”

    Stephen Fletcher, consultant anaesthetist at Bradford Teaching Hospitals Foundation NHS Trust, told the BMJ, “On paper you could double critical care capacity, turning theatres into intensive care units, but this could be practically problematic because of the numbers of nursing staff required.

    “Even if that works [and we can double critical care capacity], at some stage it is going to be inadequate, and then you go to the problem of how do you select patients for critical care?”

    “Intensivists would like and require national guidance to support critical care treatment decisions during pandemic flu. Such a nationally agreed policy is the only way to ensure equity of access to treatment and maximise outcomes for the critically ill. The guidance will also give all those caring for these patients confidence to make extremely difficult decisions at a time when NHS staff will be putting themselves at risk and making great sacrifices.”

    Despite calls from the profession, the health department has refused to support the idea of universal indemnity from litigation for clinicians during the pandemic.

    Mr Johnson told the committee that the “extraordinary pressure” faced by staff during the crisis “would be taken into account in any subsequent legal action.” But peers questioned what this assurance means in practice. “We are concerned about how this would be done,” says the report.

    Dr Fletcher also thinks that more could be done to ensure staff safety. “Emotions are likely to be running very high, and this could spill over into violence,” he said, suggesting that the government could issue orders to increase police presence in hospitals during a severe attack phase of H1N1.

    The Liberal Democrat shadow health secretary, Norman Lamb, said, “Ministers may tell us they’ve got everything under control, but frontline staff are still not receiving the support and guidance they need to prepare for the possible flood of admissions.”

    The Sunday Times reported how a 26 year old patient with H1N1 from Kilmarnock was flown to Sweden after developing adult respiratory distress syndrome (www.timesonline.co.uk, 26 Jul 2009, “Scores of swine flu victims to be sent to Europe”). The specialist NHS unit for extracorporeal membrane oxygenation was full, so the health department chartered a private jet to fly Sharon Pentleton to Karolinska University Hospital in Sweden. A spokeswoman for the department said that she was unaware of any other cases in which an NHS patient with H1N1 had been sent out of the UK for critical or specialist care.

    Notes

    Cite this as: BMJ 2009;339:b3092

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