Infrastructure

Traditionally a high level of infrastructure is needed for critical care services. Flexing these standards is possible to the extent of delivery in field hospitals as demonstrated during the 2013–6 Ebola outbreak.16 During COVID-19 many hospitals around the world developed expansion capacity in collaboration with internal medicine, respiratory and theatre teams.17 Ad hoc ICUs, whether they be in theatre space, converted general and acute beds, in new purpose-built facilities, or converted non-healthcare environments, if not supplied with the requisite utilities and familiar equipment, may lead to clinical incidents.18

Given that acuity of patient load and unit strain and proportion of created ICU beds may be related to worsening 30-day mortality,19^,20 collaboration between critical care units is crucial when coordinating the pooling of shared resources. District general hospitals with smaller critical care capacities can become overrun with rapid, staccato pulses of patients. A critical care network can allow decompression to larger hubs with greater flex capacity as evidenced by the North West London Experience in early 2020.21^,22 A (mostly) successfully coordinated strategy of active decompression was actively used in France with patients transferred intra/inter-regionally and internationally by road, rail, and air to less pressured centres.23^,24 Many patients will also require services not available locally and will need referring to networked specialty centres (i.e. a severe acute respiratory failure service).25 As a legacy of COVID-19, there has been a recognition of the need for more established adult critical care transfer services within England with multiple services now in operation (or commissioning process).26

Provision of critical care requires specialist equipment and consumables. In the initial months of COVID-19 there was a possibility that entire healthcare networks could run out of ventilators.27 Rapid innovation and regulatory cooperation allowed the design and production of a mechanical CPAP device to act as an adjunct for invasive ventilation.28 It could be argued that in hindsight, in this case this represented a distraction from the true issues at hand—not the need for more ventilators but many UK hospital's capacity to distribute oxygen. The only UK hospital to reach a near triage event was an oxygen failure at Watford.29 Likewise, industrial oxygen production and supply presented a rate-limiting step in India's response to COVID-19 with traumatic clinical and ethical outcomes.30

Research

Before COVID-19, SARS 2002–3, H1N1 2009, and the Ebola 2014–6 epidemics highlighted flaws in research infrastructure pertaining to pandemic preparedness. Disjointed coordination, imperfect understanding of disease mechanisms, patient heterogeneity, and sparse multicentre collaboration led to a challenging research space.40^,41

For a novel pathogen, having robust descriptive epidemiological data and establishing the natural history of critically ill patients at the outset of a pandemic are the first steps. Critical care services are crucial in defining this process because of their proximity to the most severe cases, and expertise in managing highly significant pathogens.42, 43, 44 Having identified a pathogen as having epidemic/pandemic potential, we are of the opinion that integrating research into the critical care response has a commanding moral and pragmatic imperative. The core processes driving the pathophysiology of a pandemic pathogen need to be investigated to best focus critical care research, as demonstrated, for example, by work into microthrombi formation.45 It has been argued that the search for treatments and the incomplete focus on basic science and pathophysiology hindered the initial response to COVID-19.46

In the UK, the coronial service not only has mandate to investigate the circumstances in which patients have died, but also to utilise inquests to formulate recommendations in order to prevent further deaths.47 In the parts of the UK, digital autopsy (the use of postmortem CT scanning) is the first-line investigation as opposed to a traditional coronial postmortem.48 This may mean key disease insights could be missed early on from lack of tissue examination (although this is the matter of debate).

Efforts were made before COVID-19 to reduce, at points, cumbersome governance and funding structures by introducing ‘sleeping’ trials (Fig. 3), dormant adaptable RCTs ready to recruit in the eventuality of a pandemic, in order to rapidly develop high-quality evidence in the early days of an outbreak culminating in the success of REMAP CAP.49 Combined with the development and integration of multi-arm adaptive platform trials allowed the rapid testing and verification of promising treatments, and minimised risk to patients. The aforementioned REMAP CAP (tocilizumab) along with RECOVERY (dexamethasone, baricitinib)50 and the yet to report HEAL COVID-1951 trials generated rapid and efficacious RCT evidence by quicky excluding ineffective treatments. Combined with the application of new messenger RNA technology, these trial methodologies generated many of the treatments that are allowing COVID-19 to transition from pandemic to endemic.52

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Fig 3

Research planning schematic.

The rapidity of knowledge sharing, and global connectivity, allowed the COVID-19 pandemic to be investigated and published in the scientific record at an unprecedented rate. That is not to say it has been an unalloyed success. By the end of May 2020 there were >1870 critical care COVID-19 articles already published.53 Such was the ‘maelstrom’ of global research, the problem became that there was too much, often poor-quality evidence.53 An interplay developed between established and social media, and the demand for promising COVID-19 research leading to the prominence of fringe or inefficacious therapies such as hydroxychloroquine and ivermectin.54^,55 Access to preprints caused issues through the promulgation and amplification of weak evidence: non-scientific media accessed not yet published studies lending an aura of authenticity to fringe treatments.56 Likewise even major journals were noted to retract published articles because of flaws in their peer review and data verification processes.57^,58

Inter- and post-pandemic research capacity has been affected by COVID-19. This is multifactorial secondary to elective surgical pauses, saturated research and funding capacity, workforce pressures, and the need to complete outstanding COVID-19 research.59 Plans should be put in place for non-pandemic research continuity during a pandemic, and realignment and de-escalation during the aftermath.60

Triage

Pandemics and epidemics may pose direct challenges to accepted socio-cultural, ethical, moral, and legal precepts. Critical care is skill and resource intensive by definition; day-to-day provision therefore is limited by reasonable skill limitations and cost implications. In the worst-case scenario, when a system fails or is unable to increment capacity to a sufficient extent, the demand for a given service may vastly outstrip supply.10 There need not be a mass catastrophe, or entire saturation of critical care capacity to provoke ethical dilemmas. Even at CRITCON 1 there is an anticipation of at least partial reallocation of staff and equipment and reprioritisation of elective work. Many of these decisions are pragmatic and equitable, however if incorrectly applied then may lead to ‘drawbridge ethics’ (where operative capacity is removed long before a pandemic arrives, in effect pulling up the drawbridge) or moral panics.75

At the most extreme, triage risks may occur. At this stage services are resource limited and interventions may even need to be removed from existing patients. For many years there have been efforts to create pandemic triage guidelines in the anticipation that critical care services may be overwhelmed. The aim of these is to provide ethical, or scientific ethical hybrid models to delineate those most appropriate to use the finite resource available.

At the simplest, some have advocated a ‘first come, first served’ approach as the most egalitatrian.76^,77 Others identify those with the best chance of benefitting from critical care by excluding those with minimal chance of surviving because of pronounced derangements in physiology or advanced comorbidities and those without need for critical care input at time of review. Various strategies can then be used to prioritise the remainder.78, 79, 80, 81, 82 Care should be paid after the admission to continually reassess whether the patient is benefitting or being harmed through invasive management, as changes in information about the patient's ability to benefit from critical care come to light or the level of acuity affecting the system change.83 So called ‘reverse triage’, removal of established support from one patient to another more likely to benefit, can be ethically justifiable but is also likely to be morally challenging for clinicians.84 Classical biomedical ethical frameworks, justice, autonomy, beneficence, and non-maleficence are a basis of many triages of resource protocols.^{74 84} No one ethical instrument can be utilised to triage, but a multi-faceted model should be adopted to operationalise complementary values.75^,85^,86 Ethical values may also not be compatible with the laws of countries in which they are applied; early engagement with legal services and regulatory bodies may be necessary.87^,88 There should be transparency in the institution of resource triage.79^,89 The National Institute for Health and Care Excellence (NICE), the Faculty of Intensive Care Medicine (FICM), and the Royal College of Physicians provide numerous recognised decision-making frameworks around treatment escalation and end-of-life decisions which provide structure.90^,91

The activation of altered triage protocols, which deny some patients critical care treatments deemed necessary by the treating clinicians, must only occur once all possible national and feasible international calls for resource have been exhausted and there is still an unmanageable demand on local resources. All decisions should be made by two experienced clinicians disconnected from the patient's care.61^,72^,84

Health inequalities

Historical examples including Māori populations in 1918–9 and 1950s New Zealand, and more recently Canadian First Nations and Indigenous Australians in 2009, demonstrate that morbidity and mortality fall heavily on historically discriminated against indigenous communities.14^,92^,93 COVID-19 has further highlighted longstanding health inequalities across underserved population groups with greater rates of disease acquisition, severity, hospital admission, organ failure, long-term morbidity, and mortality.43^,94, 95, 96 Despite making up <14% of the UK population, Black, Asian, and minority ethnic groups accounted for 19% of deaths in hospital and 35% of critical care admissions following COVID-19.97 In East London, Black and Asian patients hospitalised as a result of COVID-19 were younger and more likely to die.98, 99 These disparities are intrinsically linked to wider social determinants of health and reflect underlying inequalities with higher levels of pre-existing comorbidities, higher levels of socioeconomic deprivations, and structural determinants of healthcare access and provision.100, 101, 102 Despite improvement in overall outcomes, better treatments, and processes of care as the pandemic progressed, Asian and Black ethnic groups continued to have increased hospital admissions and death in hospital associated with COVID-19.99 This pattern was repeated in the United States where arguably high levels of inequality, lack of centralised healthcare, and polarised political views led to large disparities in clinical outcomes.103 There remains the crucial need to better identify, understand, and mitigate the driving factors to prevent continued health inequalities in the future.

Engagement with families

Increasing patients' families' engagement in their loved ones' care and their presence on the intensive care unit improves patient outcomes, and the psychological impact on their relatives.104, 105, 106, 107, 108, 109 This drive was obstructed at the outbreak of COVID-19 with more restrictive visitation policies in the interests of public health, security, and scarcity of human resource.110^,111 In the initial waves of COVID-19 these policies prevented some families from being able to stay by their relatives' sides at their deaths.105 Whilst there was understandable public health concern, it could be arguable that this is not only not in the interests of dying patients but also deleterious to the staff tasked with caring for them.112 In order to circumvent the worst sequalae of this, many critical care units introduced daily phone updates, video calling, and specific family liaison teams staffed by non-critical care clinicians.113 It is foreseeable that in the case of a different pathology (i.e. Ebola or another viral haemorrhagic fever virus), such is the significance of the pathogen that these issues would likely be compounded because of the perceived near impossibility of family visiting on public health grounds and need to provide care in isolator tents making video calls, etc., more challenging.

Training opportunities

Critical care and anaesthesia share an interwoven history in many countries. The significant overlap in patient care skillsets mean that both anaesthesia services and critical care will be profoundly affected directly and indirectly by significant pandemics.114 This is especially true when it comes to the training of the next generation of anaesthetists and critical care physicians. On a direct level occupation of theatre capacity, the redeployment and reallocation of theatre teams comes at an opportunity cost of reduced elective caseload and subspecialty training for anaesthetists.115^,116 Experientially, airway guidance advocated the most experienced intubator as first operator, potentially limiting the opportunities for trainees, at the beginning of their careers, learning core techniques (direct laryngoscopy, bag mask ventilation) over concerns surrounding droplet spread and aerosolization.115^,117 Training issues were further compounded by concerns surrounding curriculum adherence, recognition of ‘time served’, delay and format changes of mandatory examinations, reduction in overseas career development opportunities, and changes in specialty recruitment processes.115

Novel strategies needed to be adopted to continue academic and clinical teaching programmes. Zoom and Teams teaching sessions became ubiquitous and are still present in many departments today.118 Likewise, many learned societies developed online training platforms to prepare staff for the pandemic and to disseminate information and guidelines as they developed.36^,119

That is not to say pandemics are not without benefit for the training of anaesthetists and intensivists. Exposure to critical care is a cornerstone of traditional anaesthetic training, and this was without doubt abundant during the last pandemic. Complimentary and associated specialties redeployed to ICU took away a greater insight of the critically ill patient and have benefitted their own specialties through their experience, developing better communication skills, resilience, and knowledge of patient care outside of their specialty interest.120 Impressionable foundation doctors (those in rotational training during their first 2 years out of medical school) were redeployed to critical care units around the UK—this has anecdotally contributed to the large increase in demands for anaesthesia training programmes in the UK and awareness of critical care more generally.121^,122

Burnout and moral injury

On the ascent to peak activity, we have seen that multiple hazards are faced by critical care teams. Whilst the initial surges may pass by on adrenaline and morale, the long tail of weaning from organ support, an aggregation of moral injury from ceaseless mortality, a limitation of resource and crisis standards of care, a pervasive paranoia of novel pathogens, and over capacity work schedules can lead to attrition in workforce. In pandemics from SARS through Ebola through to COVID-19, healthcare workers report high levels of burnout, post-traumatic stress disorder (PTSD), concerns about pathogenic transmission to family members, and sleeping difficulties.133 Risks to team members can be divided into clinical (i.e. direct risks from the pathogen) and nonclinical risks (i.e. threats of violence, professional criticism or litigation, burnout, and other associated mental health disorders).35

Burnout is a syndrome comprising emotional exhaustion, depersonalisation, and low personal accomplishment caused by chronic exposure to the accretion of physical and mental stressors involved in providing healthcare.134 The weight of the pandemic stretched many staff beyond their elastic limit to the point of burnout and even breakage, leading to the loss of many experienced critical care nurses in the post-pandemic period.135 Burnout presents a risk to patient safety with worse outcomes from overstretched and overburdened teams.136 This can be ameliorated by providing certainty of legal safe standing and extraordinary circumstances, sharing acceptable crisis standards of care and adequate rest periods and facilities, equitable pay and conditions, appropriate protective equipment, applicable training, and supervision.35

Long-term outcomes

In addition to bearing the mental and physical scars of general critical illness complications, such as PTSD, digital injuries from pressors, ICU acquired weakness, patients can have disease specific complications from pandemic illnesses. Whilst they may not bear the visible stigmata of post-polio neuropathies or smallpox scars, the survivors of critical COVID-19 continue to suffer with persistent organ dysfunction well after the initial insult. In one large-scale study of a large United States Veterans Administration data set of the patients admitted with to critical care units with COVID-19 compared with patients admitted to hospital without a positive test, there was a 6-month hazard ratio of 13.26 for developing end stage kidney disease—this represents a truly life-changing event.137

One peculiarity of critical COVID-19 was its propensity to require attritional periods of tracheal intubation with high pressures from poorly compliant lungs. In addition, tracheostomies for profound neuromuscular weakness and parenchymal damage aggregated to lead to a remarkable incidence of tracheal lesions, including tracheo-oesophageal fistulae, subglottic stenosis, and tracheomalacia.138^,139 It is our experience that many of these complications will need outpatient surgical management, and some might lead to the need for long-term artificial airways.

Patients also bear the mental scars of their illness, for example Ebola survivors are haunted by traumatic memories of their illness, and brush with mortality. This is especially challenging in environments such as Liberia, with one psychiatrist and one mental health hospital in the country as of 2015 at the end of the outbreak.140 GPICS and NICE guidance both advocate the follow-up of critical care survivors inclusive of psychological sequalae.11

Management of critically ill pandemic survivors through their acute stay can become a Pyrrhic victory if their longer-term health needs are not met upon discharge. A structured and multidisciplinary approach is fundamental to tackling the multiple sequalae of post-pandemic critical care. The post-intensive care syndrome—a constellation of: skeletal muscle wasting and neuromuscular dysfunction, cognitive impairment, mood disorders, and speech problems can persist for many years, greatly affecting functional status and quality of life.141 This is equally applicable to post-pandemic survivors as a general ITU population.142 The Post ICU Presentation Screen Tool (PICUPS) was developed during the pandemic and is the first multiprofessional tool to facilitate selection of patients for closer follow-up and generation of an appropriate rehabilitation prescription.142^,143

As we pass the third anniversary of the initial surges of COVID-19 activity, literature is becoming available on functional outcomes of critical care survivors. Patients demonstrate persistent neuromuscular dysfunction, ongoing dyspnoea, and mental health issues in keeping with non-pandemic acute respiratory distress syndrome (ARDS) and post-intensive care syndrome (PICS).144 However, the scale is different because of the volume and incidence of COVID-19 representing a significant demand on health services. In addition to having a scalable acute response, we suggest it may be prudent to have plans made for selective scalable rehabilitation capacity and long-term critical care specific follow-up.