Use of PPE for CPR
04/05/20 15:27
Updated analysis in light of conflicting advice The Resuscitation Council and Public Health England regarding chest compressions being an aerosol generating procedure.
Moral Balance Analysis 4 - Pregnant Staff
20/04/20 13:12
Is it unethical to ask staff at some risk due to health conditions to be patient facing, when their pregnant colleagues who are at no/very little additional risk (on the basis of very limited evidence) are given the choice of being patient facing?
This Moral Balance Analysis was carried out by Nottingham University Hospitals NHS Trust's Ethics of Clinical Practice Committee on the 8th April 2020.
The full analysis can be downloaded here.
Nottingham University Hospital’s Ethics of Clinical Practice Committee considered that the ethical points and principles to consider in response to this question are:
Protecting babies and vulnerable is a societal good (high emotional cost in not doing so).
Two at risk when considering pregnant staff.
Clear factual basis for considering > 28 weeks at high risk if infection
Currently insufficient data to clarify this risk < 28 weeks
• First trimester is always considered the highest risk period for causing congenital abnormalities
• Some reassuring evidence no harm from other coronaviruses. But COVID-19 too soon to know.
Giving choice to pregnant staff may be empowering and supportive of the professionalism of staff to help patients.
Need to maintain patient safety (enough staff members) – duty of care
• Consider other roles that are not patient focusing
• Graduated response may be needed such that if pandemic worsened and patient care compromised a request for help from all staff with the requisite skills may be required (high emotional challenge if pandemic deteriorates)
Guidance from the Royal College of Obstetrics and Gynaecology that "pregnant women of any gestation should be offered the choice of whether to work in direct patient-facing roles during the COVID-19 pandemic", should be followed unless there is a strong argument against.
Fairness and consistency – do other vulnerable patient groups need similar protection as pregnant staff?
This Moral Balance Analysis was carried out by Nottingham University Hospitals NHS Trust's Ethics of Clinical Practice Committee on the 8th April 2020.
The full analysis can be downloaded here.
Nottingham University Hospital’s Ethics of Clinical Practice Committee considered that the ethical points and principles to consider in response to this question are:
Protecting babies and vulnerable is a societal good (high emotional cost in not doing so).
Two at risk when considering pregnant staff.
Clear factual basis for considering > 28 weeks at high risk if infection
Currently insufficient data to clarify this risk < 28 weeks
• First trimester is always considered the highest risk period for causing congenital abnormalities
• Some reassuring evidence no harm from other coronaviruses. But COVID-19 too soon to know.
Giving choice to pregnant staff may be empowering and supportive of the professionalism of staff to help patients.
Need to maintain patient safety (enough staff members) – duty of care
• Consider other roles that are not patient focusing
• Graduated response may be needed such that if pandemic worsened and patient care compromised a request for help from all staff with the requisite skills may be required (high emotional challenge if pandemic deteriorates)
Guidance from the Royal College of Obstetrics and Gynaecology that "pregnant women of any gestation should be offered the choice of whether to work in direct patient-facing roles during the COVID-19 pandemic", should be followed unless there is a strong argument against.
Fairness and consistency – do other vulnerable patient groups need similar protection as pregnant staff?
CRITCON Levels - winter flu vs pandemic
03/04/20 14:24
CRITCON Levels are based (though for some reason are in reverse order) to DEFCON levels which tells us how close we are to nuclear war.
They have been modified for use by critical care networks in Winter Flu to describe the strain an ICU is under. See London Critical Care Network example.
CRITCON levels for Winter Flu do not work as well in pandemic situations. The difference is that the CRITCON levels for Winter Flu were designed to describe the current number of ICU patients and how they may, or may not be exceeding normal bed capacity. The desired ambition is to get the numbers of patients back within the normal bed state.
In pandemic situations the desire is to open many more additional beds than normal and hold those beds open until the pandemic subsides. ICU capacity is created for future patients who are not even here yet. The result is that one actually can have many empty beds, at least initially.
In the example above from London only at CRITCON Level 3, which is only one better than disaster, is elective surgery minimised to urgent/cancer and lifesaving only and the Trust operating at or near maximum physical capacity. Yet what we have seen in pandemic planning is that elective surgery was minimised very early and the Trusts have many empty beds, even before normal ICU capacity was exceeded.
Last night on my ICU we would on patient numbers alone be CRITCON 1, yet had opened extra quasi-critical care areas CRITCON 2, and had minimised surgery CRITCON 3.
So below is a table that proposes Pandemic CRITCON Levels that we hope better explains what we are observing during COVID-19 as well as gives proposed guidance on the ethical steps that may need to be made in patient care when resources are simply not available. My ICU would, by this system, still be Pandemic CRITCON 1. I hope it stays this way.
They have been modified for use by critical care networks in Winter Flu to describe the strain an ICU is under. See London Critical Care Network example.
CRITCON levels for Winter Flu do not work as well in pandemic situations. The difference is that the CRITCON levels for Winter Flu were designed to describe the current number of ICU patients and how they may, or may not be exceeding normal bed capacity. The desired ambition is to get the numbers of patients back within the normal bed state.
In pandemic situations the desire is to open many more additional beds than normal and hold those beds open until the pandemic subsides. ICU capacity is created for future patients who are not even here yet. The result is that one actually can have many empty beds, at least initially.
In the example above from London only at CRITCON Level 3, which is only one better than disaster, is elective surgery minimised to urgent/cancer and lifesaving only and the Trust operating at or near maximum physical capacity. Yet what we have seen in pandemic planning is that elective surgery was minimised very early and the Trusts have many empty beds, even before normal ICU capacity was exceeded.
Last night on my ICU we would on patient numbers alone be CRITCON 1, yet had opened extra quasi-critical care areas CRITCON 2, and had minimised surgery CRITCON 3.
So below is a table that proposes Pandemic CRITCON Levels that we hope better explains what we are observing during COVID-19 as well as gives proposed guidance on the ethical steps that may need to be made in patient care when resources are simply not available. My ICU would, by this system, still be Pandemic CRITCON 1. I hope it stays this way.
Differences between mass casualty triage and pandemic
31/03/20 14:36
New one-page MORAL Balance Framework
29/03/20 10:12
We have created a new one-page version of MORAL Balance.
It lacks the Balancing Box - but may allow for quicker use and documentation.
First - be clear about what decision you are trying to make.
Second - identify and Make sure of the facts and Outcomes of Relevance to the Agents (an agent is anyone who cares about or is impacted by the decision).
Third - Level out the arguments. Try and achieve a Balanced decision.
Fourth - document decision (use the framework to guide documentation or place this sheet in the notes)
It lacks the Balancing Box - but may allow for quicker use and documentation.
First - be clear about what decision you are trying to make.
Second - identify and Make sure of the facts and Outcomes of Relevance to the Agents (an agent is anyone who cares about or is impacted by the decision).
Third - Level out the arguments. Try and achieve a Balanced decision.
Fourth - document decision (use the framework to guide documentation or place this sheet in the notes)