Definitive Care for the Critically Ill During a Disaster
Report of the Task Force for Mass Critical Care of the American College of Chest Physicians Released
By Richard E. Waldhorn, M.D., May 15, 2008
The Department of Homeland Security National Planning Scenarios predict that a catastrophic natural disaster, an improvised nuclear device, a large-scale bioattack, or a severe pandemic could produce tens of thousands of critically ill patients in a metropolitan area. How should hospitals with critical care units plan for the development of significant surge capacity and for the allocation of scarce resources when surge capacity is overwhelmed?
In a supplement to the May issue of CHEST, the journal of the American College of Chest Physicians, 4 articles outline an approach to planning and implementing mass critical care during a disaster.1 The first article reviews the existing state of emergency preparedness for mass critical illness and current mass critical care response capabilities and limitations. The second suggests an alternative approach, termed emergency mass critical care (EMCC) that would provide only essential critical care for surge capacity. The specific types of equipment and supplies, staffing requirements, and treatment spaces required for EMCC are presented in the third article. In the final article, the Task Force suggests a framework for allocation of scarce critical care resources after all efforts at augmentation, including the implementation of EMCC, have been exceeded.
The 4 articles in the supplement, summarized below, result from the work of the 37-member multidisciplinary Task Force for Mass Critical Care, which is composed of experts in critical care, emergency medicine, bioethics, law, and nursing and state, local, and federal emergency planners. (Note: The Center for Biosecurity was represented on the Task Force by the author of this CBN article.)
Article 1—Definitive Care for the Critically Ill During a Disaster: Current Capabilities and Limitations2 reviews current critical care capacities in “stuff, staff, and space” and establishes the premise for the development of the other 3 documents:
Baseline shortages of critical care staff, supplies, and treatment spaces exist that would limit the number of critically ill patients who could receive care in a mass casualty event.
Estimates of the total number of full-feature mechanical ventilators in the U.S. range from 53,000 to 105,000, but only a minimal number of reserve ventilators are available on a site at any time. The logistical hurdles to distributing excess ventilators to an area of need during a disaster will be formidable.
“Just in time” supply chain management, baseline shortages in critical care staff and deficiencies in training physicians and hospital administrators to respond to a disaster contribute to limitations in current critical care capacity.
Mutual aid for healthcare facilities through redistribution of critically ill patients is likely to be of little benefit in a mass casualty event because of the limitations of local, regional, and national patient evacuation and transport systems.
Importing physicians and resources such as NDMS DMAT teams would probably take too long and be of limited help in augmenting critical care capacity.
Article 2—Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity3 suggests the following alternative approach to augment critical care capacity in a disaster where reliance on mutual aid and outside assistance and resources will be problematic:
Every hospital with an ICU should develop a plan to shift critical care to augmented, essential emergency mass critical care (EMCC) rather than to marginally increase unrestricted critical care.
Planning and response should be done in coordination with regional coalitions of healthcare systems and public health organizations to allow for graded, uniform implementation of altered critical care processes.
Hospitals should plan for 3 times the usual ICU capacity, and they should plan to sustain the EMCC approach for at least 10 days.
Recommended treatment modalities in EMCC include mechanical ventilation, IV fluid resuscitation, vasopressor administration, antimicrobials and antidotes, sedation and analgesia, and optimal therapeutics such as renal replacement therapy and nutrition.
Article 3—Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity4 suggests specific quantities and types of critical care equipment, staffing models, and treatment spaces for the provision of limited, essential EMCC:
Since most patients who will require mechanical ventilation during a mass critical care event will have a severe lung injury or airflow obstruction, one ventilator will be needed for each patient receiving EMCC. Strategies that have been described to use a single ventilator with multiple-limbed circuitry would likely only have utility in ventilating patients with normal lungs, such as those with traumatic brain injury.
Characteristics of positive-pressure mechanical ventilators best suited to augment surge capacity include: (1) the ability to ventilate and oxygenate adult and pediatric patients; (2) the capacity to function with low-flow oxygen without high-pressure medical gas; supply of oxygen and maintenance of hospital oxygen pressure when multiple ventilators are simultaneously drawing high-flow oxygen through piping systems not typically designed with this capacity will be difficult; (3) the ability to deliver a prescribed minute ventilation when patients are not breathing spontaneously; and (4) sufficient alarms to alert staff to ventilator malfunction or acute changes in airway pressures.
Staffing models are suggested that would use non–critical care nursing staff trained in a core set of competencies as part of collaborative critical care teams. At a minimum, caregivers should be competent in infection control practices, patient turning and cleaning, suctioning and airway maintenance, vital signs and monitoring, urinary catheter care and management of wastes, and the delivery of medications and nutrition when applicable.
The authors caution that all staffing models that rely on the reassignment of non–critical care professionals to critical care may have deleterious effects on patient care in other areas of hospitals. Allocation of staff for EMCC must be a dynamic process matched to the circumstances of the disaster to ensure that the fewest number of patients are harmed by staffing shortages.
Article 4—Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care5 attempts to tackle the complex medical, ethical, legal, and organizational issues in planning for the allocation of scarce resources in a situation that would overwhelm the critical care capacity of all communities in the country simultaneously, such as a severe influenza pandemic:
Hospitals need to have a uniform and cooperative approach to allocation of scarce resources. All attempts to develop surge capacity or transfer patients to facilities with more capacity must be exhausted before triage protocols are considered.
Patients would meet inclusion criteria for critical care triage protocols only if they require critical care interventions such as mechanical ventilation or vasopressors; patients who require observation only would not be admitted to a critical care area.
The suggested exclusion criteria for critical care are based on two severity-of-illness scoring systems. The Sequential Organ Failure Assessment (SOFA) score is based on standard physiologic parameters and simple laboratory tests and would be calculated on admission and then daily to assess acute inpatient severity of illness. A second component of the exclusion criteria is based on the severity of underlying chronic illness. Patients with short life expectancy due to diseases such as end-stage organ failure, advanced untreatable metastatic malignancy, or an irreversible neurologic event would meet exclusion criteria.
Based on these inclusion and exclusion criteria and on daily severity-of-illness scores, a triage officer and triage team would prioritize patients from least sick to most severely ill and interact with clinical teams, palliative care staff, and administrative entities to allocate scarce critical care resources.
Patients not eligible for critical care would continue to receive supportive and palliative care.
Key ethical principles that would govern the allocation of scarce resources include a new paradigm of limitation of individual autonomy. The recent California Healthcare Surge Guidelines referred to this as a shift from individual- to population-based care.6 The Task Force recognized that allocation of scarce resources will require decisions based on objective criteria rather than on patient, family, or provider choices. These decisions must be transparent, and “procedural justice” should be ensured and monitored continuously.
Legal protection for providers through government action is needed to ensure consistent allocation of critical care resources across institutions in extreme circumstances under which a triage algorithm would be activated.
Several caveats are offered regarding the work on allocation of scarce resources. There is a paucity of evidence-based information on mass critical care practice; thus, guidelines and protocols are based on extrapolation from the use of these parameters and assessment systems in everyday ICU care. The Task Force views this effort as a work in progress and has called for more research on the outcome validity of the suggested triage processes through the use of retrospective reviews and modeling work.
Devereaux A, Christian MD, Dichter JR, Geiling JA, Rubinson L. Summary of suggestions from the Task Force for Mass Critical Care Summit, January 26-27, 2007. Chest 2008;133(suppl):1S-7. http://www.chestjournal.org/cgi/content/full/133/5_suppl/1S. Accessed May 14, 2008.
Christian MD, Devereaux AV, Dichter JR, Geiling JA, Rubinson L. Definitive care for the critically ill during a disaster: current capabilities and limitations. Chest 2008;133(suppl):8S-17. http://www.chestjournal.org/cgi/content/abstract/133/5_suppl/8S. Accessed May 14, 2008.
Rubinson L, Hick JL, Hanfling DG, et al. Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity. Chest 2008(suppl);133:18S-31. http://www.chestjournal.org/cgi/content/abstract/133/5_suppl/18S. Accessed May 14, 2008.
Rubinson L, Hick JL, Curtis JR, et al. Definitive care for the critically ill during a disaster: medical resources for surge capacity. Chest 2008;133(suppl):32S-50. http://www.chestjournal.org/cgi/
content/abstract/133/5_suppl/32S. Accessed May 14, 2008.
Devereaux AV, Dichter JR, Christian MD, et al. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Chest 2008;133(suppl):51S-66. http://www.chestjournal.org/cgi/content/abstract/
133/5_suppl/51S. Accessed May 14, 2008.
Surge standards guidelines. California Department of Public Health. http://bepreparedcalifornia.ca.gov/EPO/CDPHPrograms/ PublicHealthPrograms/EmergencyPreparednessOffice/ EPOProgramsServices/Surge/SurgeStandardsGuidelines/. Accessed May 14, 2008.