Tom Nolan: Critical care and the pandemic panic

A pandemic of panic

A “panic pandemic” is worsening the crisis in the UK said health ministers over the weekend. Andy Burnham, the health secretary, told The Observer of the need for people to keep a sense of perspective.

“If people are made unnecessarily anxious, it makes the lives of NHS professionals, who are already under enormous pressure, far more difficult as people become unduly worried.”

His plea was backed up by the president of the Royal College of Paediatrics and Child Health, Professor Terence Stephenson:

“Health services struggle when they are overwhelmed by people who don’t need to be there. There are 11 million children in England and 256 of them are in hospital [with swine flu]. For the four families where children have died, it is an absolute tragedy, but if you are talking about a previously healthy child where swine flu has led to their death, there have been none.”

The RCGP chairman Professor Stephen Field concurs:

“This is almost like the phoney war at the moment. The big danger and real threat is that there will be a big spike in the numbers of people with influenza in the autumn.”

Meanwhile, opposition parties have been continuing to blame the government for launching the new national flu pandemic service too late. Andrew Landsley, health spokesman for the Conservatives, has described it as “too little, too late”. Unfair, say the Government: it was doctors who told us not to launch this until the flu was more prevalent. Michele Drage of the Londonwide LMCs said to GPs that the first night after the service launched she had reports that “flu-related demand on OOH services dropped off significantly.”

Will there be a critical care bed shortage?

A 26 year old pregnant woman was flown from Scotland to Sweden last week to receive extracorporeal membrane oxygenation (ECMO). She developed acute respiratory failure after falling ill with swine flu. The five ECMO beds in the UK (in Leicester) were full. As you might expect, this sparked accusations by politicians about the UK not having enough intensive care capacity. Are they right?

A study in the journal Anaesthesia has modelled possible outcomes from the present pandemic in England. They took population statistics and number of intensive care beds (adult and paediatrics), total number of ventilators (assumed to be equal to the number of intensive care beds). They assumed that 36% of those admitted will require critical care and half of those will need ventilating. This is much higher than current rates (under 10% according to HPA figures), although admission criteria might be expected to become stricter as the case load increases in the coming months. Using historical assumptions for the hospitalisation rate they estimated whether there will be enough critical care beds and ventilators. Assuming a hospitalisation rate of 0.25%, critical care bed occupancy in England would be 160%. Demand for ventilators would be 78% of total capacity. The most overwhelmed area would be the South East Coast region at 230% bed occupancy.

The authors of this study note the considerable difficulties in modelling the pandemic at such an early stage. However, even taking this into account, they seem concerned:

Best case predictions suggest that all critical care beds will be filled with influenza A ⁄ H1N1 patients if the hospital admission rate is greater than 0.25%. Worryingly, even small increases to the observed admission rate make the overwhelming scenario increasingly statistically credible.

That shouldn’t worry the people of Exeter though. The San Francisco Sentinel reports that Exeter’s 19th century catacombs are being readied for use as a mass swine flu grave. A city council spokesperson gave the following quote:

“We have some empty catacombs in an old cemetery in the city,” he said. “These are 19th century underground burial chambers which are normally a tourist attraction. They can, however, be safely used for their original purpose and allow us to temporarily store bodies in the remote possibility that the need should arise.”