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Recent Developments in Respiratory Surge Preparedness

By Eric Toner, M.D., May 3, 2007

In the event of a disaster that causes an overwhelming number of patients to suffer respiratory failure, such as a severe influenza pandemic, clinicians could face two particularly difficult resource-related problems--finding a way to augment the limited number of respiratory care specialists and deciding how to allocate a limited number of mechanical ventilators [1]. Two recent developments in the field offer potential remedies.

Respiratory Care Training to Augment Limited Numbers of Respiratory Therapists

On April 30, 2007, the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health and Human Services (HHS) released a training DVD designed to teach medical professionals who are not respiratory care specialists the essentials of respiratory care and ventilator management. The DVD was produced by Michael Hanley, M.D., and colleagues at the Denver Health Medical Center, as part of the AHRQ-funded Project XTREME (Cross-Training Respiratory Extenders for Medical Emergencies). The program’s six modules cover infection control, respiratory care terms and definitions, manual ventilation, mechanical ventilation (using the two types of ventilators included in the Strategic National Stockpile), airway maintenance, and airway suctioning. The modules also include quizzes to assess the trainee’s knowledge.

While there is an existing shortage of healthcare workers (HCWs) across the board, which would likely worsen in a pandemic, a shortage of HCWs with specialized skills, such as ICU nurses and respiratory therapists, would present a particular challenge since they cannot be easily replaced by HCWs with general skills. One potential way to augment the ranks of such specialists in a crisis would be to employ non-specialized HCWs who can be given specific, rapid training (“just-in time training”), using materials that have been  prepared in advance, such as this new training DVD. This DVD is available free of charge by calling 1-800-358-9295 or by sending an e-mail to ahrqpubs@ahrq.gov. The DVD is accompanied by a report entitled, Model for Health Professionals’ Cross-Training for Mass Casualty Respiratory Needs, which provides information on the training model and the research that guided its development.

A Decision-Making Framework for Allocation of Scarce Ventilators

On March 15, 2007, the New York State Workgroup on Ventilator Allocation in an Influenza Pandemic and the New York State Task Force on Life and the Law issued a draft document for public comment entitled “Allocation of Ventilators in an influenza Pandemic: Planning Document.” This 52-page document proposes an ethical framework, a specific process, and criteria for making very difficult decisions about who should receive life saving care when demand is high and the number of ventilators available is insufficient. Because of the difficult and delicate ethical and legal issues inherent in such a proposal, the workgroup is explicitly requesting review, discussion, and comment from the professional community and the public. Comments and questions on the planning document may be submitted to panflu@health.state.ny.us.

After incorporating public feedback, the revised final document will be issued as voluntary, non-binding guidance for healthcare workers and facilities. The intent is to pair these guidelines with legislation that would provide immunity to professional liability suits to those health care providers who follow them.The details of the proposed criteria are beyond the scope of this brief report but are worthy of careful review by clinicians who may someday have to use them. Key elements are summarized below:

  1. Pre-triage requirements: Facilities must reduce the need for ventilators and expand resources before instituting ventilator triage procedures. 

  2. Patient categories for triage: All patients in acute care facilities will be equally subject to triage guidelines, regardless of their disease category or role in the community.

  3. Implications of triage for facilities: State-wide consistency will prevent inequities; chronic care facilities will maintain standards different from those of acute care facilities.

  4. Clinical evaluation: Clinicians will evaluate patients based on universally applied objective criteria and offer time-based trials of ventilator support.

  5. Triage decision-makers: Supervising physicians will take responsibility for triage decisions. Primary care clinicians will care for patients and will not determine ventilator allocation.

  6. Palliative care: Palliative care will play a crucial role in providing comfort to patients, including those who do not receive ventilator treatment.

  7. Appeals process: Physicians and patients must have a mechanism for requesting review of triage decisions; ethics committee members and others should be prepared to assist in the appeals process.

  8. Communication about triage: Government and clinicians need to provide clear, accurate and consistent communication about triage guidelines. Data gathering and public comment can help improve the triage system.

New York State's DOH has made an admirable first attempt at creating a state-wide approach to allocation of scarce resources, rationing of care, or alteration of standards of care, and it is a very important first step. A similar national approach to these issues is also needed. After appropriate review and vetting, this document could serve as the foundation for regional and national guidelines for allocation of scarce resources.

References

  1. Hick J, O'Laughlin D. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med;13:223-229. Available at: http://intl.aemj.org/cgi/content/full/13/2/223. Accessed May 3, 2007 

  2. AHRQ web site. Project XTREME. Available at: http://www.ahrq.gov/prep/projxtreme/. Accessed May 1, 20073. New York State Department of Health website. Pandemic Influenza Plan, Allocation of Ventilators in an Influenza Pandemic. Available at: http://www.health.state.ny.us/diseases/communicable/influenza/ pandemic/ventilators/docs/ventilator_guidance.pdf. Accessed May 1, 2007