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_|Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26?27, 2007|_
[THIS POST CONTAIN AN EXECUTIVE SUMMARY AND FOUR ABSTRACTS FROM CHEST REVIEW - via CIDRAP - IOH]
(1a) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26?27, 2007*
Asha Devereaux, MD; Michael D. Christian, MD, FRCPC; Jeffrey R. Dichter, MD; James A. Geiling, MD, FCCP; Lewis Rubinson, MD, PhD? - (CHEST 2008; 133:1S?7S)
Key words: alternate standards of care; critical care; critical care assessment teams; disaster critical care; disaster medicine; disaster triage; ethics; health-care worker and disaster; mass casualty;
mass casualty critical care; mass casualty respiratory failure; triage; triage teams; mass critical care; psychological impact of disaster
Abbreviation: EMCC emergency mass critical care
Executive Summary
This Supplement on the management of mass critical care for ill patients represents the consensus opinion of a multidisciplinary panel convened under the umbrella of the Critical Care Collaborative Initiative.
Expert recommendations on this subject are needed.
Most countries have insufficient critical care staff, medical equipment, and ICU space to provide timely, usual critical care to a surge of critically ill victims.
If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health-care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing.
As a result, US and Canadian authorities1,2 have called for the development of comprehensive plans for managing mass casualty events, particularly for the provision of critical care.
This Supplement includes the following:
(1) a review of current US and Canadian baseline critical care preparedness and response capabilities and limitations,
(2) a suggested framework for critical care surge capacity,
(3) suggestions for minimum resources ICUs will need for mass critical care, and
(4) a suggested framework for allocation of scarce critical care resources when critical care surge capacity remains insufficient to meet need.
This Supplement is intended to aid clinicians and disaster planners in providing a coordinated and uniform response to mass critical care.
Mass casualty events occur frequently worldwide.3 Fortunately, the vast majority of these do not generate overwhelming numbers of critically ill victims.
Attention to mass critical care, however, has been stimulated by the severe acute respiratory syndrome epidemic of 2002?2003,4,5 recent natural disasters, concern for intentional catastrophes, and the looming threat of a serious influenza pandemic.1,6?11
To guide preparedness for such events, the Task Force for Mass Critical Care (hereafter referred to as the Task Force) was convened. It comprised 37 experts from fields including bioethics, critical care, disaster preparedness and response, emergency medical services, emergency medicine, infectious diseases, hospital medicine, law, military medicine, nursing, pharmacy, respiratory care, and local, state, and federal government planning and response. Several members of the Critical Care Collaborative (http://www.chestnet.org/institutes/cci/ccc.php) initiated the project and assembled a steering committee for project development and administration. Members of this steering committee included representatives from the organizational members of the Critical Care Collaborative as well as several unaffiliated North American disaster experts. This steering committee then selected members of the broader Task Force on the basis of their expertise and experience.
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(1b) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: Current Capabilities and Limitations*
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Michael D. Christian, MD, FRCPC; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; James A. Geiling, MD, FCCP and Lewis Rubinson, MD, PhD
* From the Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), White River Junction, VT; and University of Washington (Dr. Rubinson), Seattle, WA. A list of Task Force members is given in the Appendix.
Correspondence to: Michael D. Christian, MD, FRCPC, Mount Sinai Hospital, 600 University Ave, Suite 18-206, Toronto, ON, Canada M5G 1X5; e-mail: michael.christian@utoronto.ca
In the twentieth century, rarely have mass casualty events yielded hundreds or thousands of critically ill patients requiring definitive critical care.
However, future catastrophic natural disasters, epidemics or pandemics, nuclear device detonations, or large chemical exposures may change usual disaster epidemiology and require a large critical care response.
This article reviews the existing state of emergency preparedness for mass critical illness and presents an analysis of limitations to support the suggestions of the Task Force on Mass Casualty Critical Care, which are presented in subsequent articles.
Baseline shortages of specialized resources such as critical care staff, medical supplies, and treatment spaces are likely to limit the number of critically ill victims who can receive life-sustaining interventions. The deficiency in critical care surge capacity is exacerbated by lack of a sufficient framework to integrate critical care within the overall institutional response and coordination of critical care across local institutions and broader geographic areas.
Key Words: disaster medicine ? influenza pandemic ? mass casualty medical care ? surge capacity
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LINK for all the four abstracts: CHEST
(1c) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Lewis Rubinson, MD, PhD; John L. Hick, MD; Dan G. Hanfling, MD; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Michael D. Christian, MD; Daniel Talmor, MD, MPH, FCCP; Justine Medina, RN, MS; J. Randall Curtis, MD, MPH, FCCP and James A. Geiling, MD, FCCP
* From the University of Washington (Dr. Rubinson), Seattle, WA; Hennepin County Medical Center (Dr. Hick), Minneapolis, MN; Inova Fairfax Hospital (Dr. Hanfling), Falls Church, VA; Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Beth Israel Deaconess Medical Center (Dr. Talmor), Boston, MA; American Association of Critical Care Nurses (J. Medina), Aliso Viejo, CA; Harbor View Medical Center (Dr. Curtis), Seattle, WA; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), Hanover NH. A list of Task Force members is given in the Appendix.
Correspondence to: Lewis Rubinson, MD, PhD, University of Washington, Harborview Medical Center, Campus Box 359762, 325 Ninth Ave, Seattle, WA 98104; e-mail: rubinson@u.washington.edu
Background:
Plausible disasters may yield hundreds or thousands of critically ill victims. However, most countries, including those with widely available critical care services, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. Shifting critical care disaster preparedness efforts to augment limited, essential critical care (emergency mass critical care [EMCC]), rather than to marginally increase unrestricted, individual-focused critical care may provide many additional people with access to life-sustaining interventions. In 2007, in response to the increasing concern over a severe influenza pandemic, the Task Force on Mass Critical Care (hereafter called the Task Force) convened to suggest the essential critical care therapeutics and interventions for EMCC.
Task Force suggestions: EMCC should include the following: (1) mechanical ventilation, (2) IV fluid resuscitation, (3) vasopressor administration, (4) medication administration for specific disease states (eg, antimicrobials and antidotes), (5) sedation and analgesia, and (6) select practices to reduce adverse consequences of critical illness and critical care delivery. Also, all hospitals with ICUs should prepare to deliver EMCC for a daily critical care census at three times their usual ICU capacity for up to 10 days.
Discussion:
By using the Task Force suggestions for EMCC, communities may better prepare to deliver augmented critical care in response to disasters. In light of current mass critical care data limitations, the Task Force suggestions were developed to guide preparedness but are not intended as strict policy mandates. Additional research is required to evaluate EMCC and revise the strategy as warranted.
Key Words: critical care surge capacity ? disaster medicine ? influenza pandemic ? mass casualty medical care ? medical surge capacity
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(1d) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity*
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Lewis Rubinson, MD, PhD; John L. Hick, MD; J. Randall Curtis, MD, MPH, FCCP; Richard D. Branson, MS, RRT; Suzi Burns, RN, MSN, RRT; Michael D. Christian, MD; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Daniel Talmor, MD, MPH, FCCP; Brian Erstad, PharmD; Justine Medina, RN, MS and James A. Geiling, MD, FCCP
* From the University of Washington (Dr. Rubinson), Seattle, WA; Hennepin County Medical Center (Dr. Hick), Minneapolis, MN; Harbor View Medical Center (Dr. Curtis), Seattle, WA; University of Cincinnati (Mr. Branson), Cincinnati, OH; University of Virginia (Ms. Burns), Charlottesville, VA; Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; Beth Israel Deaconess Medical Center (Dr. Talmor), Boston, MA; University of Arizona (Dr. Erstad), Tucson, AZ; American Association of Critical Care Nurses (Ms. Medina), Aliso Viejo, CA; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), Hanover, NH. A list of Task Force members is given in the Appendix.
Correspondence to: Lewis Rubinson, MD, PhD, University of Washington, Harborview Medical Center, Campus Box 359762, 325 Ninth Ave, Seattle, WA 98104; e-mail: rubinson@u.washington.edu
Background:
Mass numbers of critically ill disaster victims will stress the abilities of health-care systems to maintain usual critical care services for all in need. To enhance the number of patients who can receive life-sustaining interventions, the Task Force on Mass Critical Care (hereafter termed the Task Force) has suggested a framework for providing limited, essential critical care, termed emergency mass critical care (EMCC). This article suggests medical equipment, concepts to expand treatment spaces, and staffing models for EMCC.
Methods:
Consensus suggestions for EMCC were derived from published clinical practice guidelines and medical resource utilization data for the everyday critical care conditions that are anticipated to predominate during mass critical care events. When necessary, expert opinion was used.
Task Force major suggestions:
The Task Force makes the following suggestions: (1) one mechanical ventilator that meets specific characteristics, as well as a set of consumable and durable medical equipment, should be provided for each EMCC patient; (2) EMCC should be provided in hospitals or similarly equipped structures; after ICUs, postanesthesia care units, and emergency departments all reach capacity, hospital locations should be repurposed for EMCC in the following order: (A) step-down units and large procedure suites, (B) telemetry units, and (C) hospital wards; and (3) hospitals can extend the provision of critical care using non-critical care personnel via a deliberate model of delegation to match staff competencies with patient needs.
Discussion:
By using the Task Force suggestions for adequate supplies of medical equipment, appropriate treatment space, and trained staff, communities may better prepare to deliver augmented essential critical care in response to disasters.
Key Words: disaster medicine ? influenza pandemic ? mass casualty medical care ? medical surge capacity
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(1e) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care*
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Michael D. Christian, MD, FRCPC; Nancy N. Dubler, LLB; Christian E. Sandrock, MD, MPH, FCCP; John L. Hick, MD; Tia Powell, MD; James A. Geiling, MD, FCCP; Dennis E. Amundson, CAPT, MC, USN, FCCP; Tom E. Baudendistel, MD; Dana A. Braner, MD; Mike A. Klein, JD; Kenneth A. Berkowitz, MD, FCCP; J. Randall Curtis, MD, MPH, FCCP and Lewis Rubinson, MD, PhD
* From Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Montefiore Medical Center (Ms. Dubler), New York, NY; University of California, Davis (Dr. Sandrock), Davis, CA; Hennepin County Medical Center (Dr. Hick), Minneapolis, MN; New York State Task Force on Life and the Law (Dr. Powell and Mr. Klein), New York, NY; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), Hanover NH; Naval Medical Center (Dr. Amundson), San Diego, CA; California Pacific Medical Center (Dr. Baudendistel), San Francisco, CA; Oregon Health and Sciences Center (Dr. Braner), Portland, OR; VHA National Center for Ethics in Health Care and the New York University School of Medicine (Dr. Berkowitz), New York, NY; Harbor View Medical Center (Dr. Curtis), Seattle, WA; University of Washington (Dr. Rubinson), Seattle, WA. A list of Task Force members is given in the Appendix.
Correspondence to: Asha Devereaux, MD, MPH, 1224 Tenth St, #205, Coronado, CA 92118; e-mail: ADevereaux@pol.net
Background:
Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources.
Task Force suggestions:
In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.
Key Words: critical care ? disaster ? ethics ? health-care rationing ? health-care worker ? palliative medicine ? posttraumatic stress ? triage
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(1a) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26?27, 2007*
Asha Devereaux, MD; Michael D. Christian, MD, FRCPC; Jeffrey R. Dichter, MD; James A. Geiling, MD, FCCP; Lewis Rubinson, MD, PhD? - (CHEST 2008; 133:1S?7S)
Key words: alternate standards of care; critical care; critical care assessment teams; disaster critical care; disaster medicine; disaster triage; ethics; health-care worker and disaster; mass casualty;
mass casualty critical care; mass casualty respiratory failure; triage; triage teams; mass critical care; psychological impact of disaster
Abbreviation: EMCC emergency mass critical care
Executive Summary
This Supplement on the management of mass critical care for ill patients represents the consensus opinion of a multidisciplinary panel convened under the umbrella of the Critical Care Collaborative Initiative.
Expert recommendations on this subject are needed.
Most countries have insufficient critical care staff, medical equipment, and ICU space to provide timely, usual critical care to a surge of critically ill victims.
If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health-care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing.
As a result, US and Canadian authorities1,2 have called for the development of comprehensive plans for managing mass casualty events, particularly for the provision of critical care.
This Supplement includes the following:
(1) a review of current US and Canadian baseline critical care preparedness and response capabilities and limitations,
(2) a suggested framework for critical care surge capacity,
(3) suggestions for minimum resources ICUs will need for mass critical care, and
(4) a suggested framework for allocation of scarce critical care resources when critical care surge capacity remains insufficient to meet need.
This Supplement is intended to aid clinicians and disaster planners in providing a coordinated and uniform response to mass critical care.
Mass casualty events occur frequently worldwide.3 Fortunately, the vast majority of these do not generate overwhelming numbers of critically ill victims.
Attention to mass critical care, however, has been stimulated by the severe acute respiratory syndrome epidemic of 2002?2003,4,5 recent natural disasters, concern for intentional catastrophes, and the looming threat of a serious influenza pandemic.1,6?11
To guide preparedness for such events, the Task Force for Mass Critical Care (hereafter referred to as the Task Force) was convened. It comprised 37 experts from fields including bioethics, critical care, disaster preparedness and response, emergency medical services, emergency medicine, infectious diseases, hospital medicine, law, military medicine, nursing, pharmacy, respiratory care, and local, state, and federal government planning and response. Several members of the Critical Care Collaborative (http://www.chestnet.org/institutes/cci/ccc.php) initiated the project and assembled a steering committee for project development and administration. Members of this steering committee included representatives from the organizational members of the Critical Care Collaborative as well as several unaffiliated North American disaster experts. This steering committee then selected members of the broader Task Force on the basis of their expertise and experience.
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(1b) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: Current Capabilities and Limitations*
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Michael D. Christian, MD, FRCPC; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; James A. Geiling, MD, FCCP and Lewis Rubinson, MD, PhD
* From the Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), White River Junction, VT; and University of Washington (Dr. Rubinson), Seattle, WA. A list of Task Force members is given in the Appendix.
Correspondence to: Michael D. Christian, MD, FRCPC, Mount Sinai Hospital, 600 University Ave, Suite 18-206, Toronto, ON, Canada M5G 1X5; e-mail: michael.christian@utoronto.ca
In the twentieth century, rarely have mass casualty events yielded hundreds or thousands of critically ill patients requiring definitive critical care.
However, future catastrophic natural disasters, epidemics or pandemics, nuclear device detonations, or large chemical exposures may change usual disaster epidemiology and require a large critical care response.
This article reviews the existing state of emergency preparedness for mass critical illness and presents an analysis of limitations to support the suggestions of the Task Force on Mass Casualty Critical Care, which are presented in subsequent articles.
Baseline shortages of specialized resources such as critical care staff, medical supplies, and treatment spaces are likely to limit the number of critically ill victims who can receive life-sustaining interventions. The deficiency in critical care surge capacity is exacerbated by lack of a sufficient framework to integrate critical care within the overall institutional response and coordination of critical care across local institutions and broader geographic areas.
Key Words: disaster medicine ? influenza pandemic ? mass casualty medical care ? surge capacity
---------
-
LINK for all the four abstracts: CHEST
(1c) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Lewis Rubinson, MD, PhD; John L. Hick, MD; Dan G. Hanfling, MD; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Michael D. Christian, MD; Daniel Talmor, MD, MPH, FCCP; Justine Medina, RN, MS; J. Randall Curtis, MD, MPH, FCCP and James A. Geiling, MD, FCCP
* From the University of Washington (Dr. Rubinson), Seattle, WA; Hennepin County Medical Center (Dr. Hick), Minneapolis, MN; Inova Fairfax Hospital (Dr. Hanfling), Falls Church, VA; Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Beth Israel Deaconess Medical Center (Dr. Talmor), Boston, MA; American Association of Critical Care Nurses (J. Medina), Aliso Viejo, CA; Harbor View Medical Center (Dr. Curtis), Seattle, WA; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), Hanover NH. A list of Task Force members is given in the Appendix.
Correspondence to: Lewis Rubinson, MD, PhD, University of Washington, Harborview Medical Center, Campus Box 359762, 325 Ninth Ave, Seattle, WA 98104; e-mail: rubinson@u.washington.edu
Background:
Plausible disasters may yield hundreds or thousands of critically ill victims. However, most countries, including those with widely available critical care services, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. Shifting critical care disaster preparedness efforts to augment limited, essential critical care (emergency mass critical care [EMCC]), rather than to marginally increase unrestricted, individual-focused critical care may provide many additional people with access to life-sustaining interventions. In 2007, in response to the increasing concern over a severe influenza pandemic, the Task Force on Mass Critical Care (hereafter called the Task Force) convened to suggest the essential critical care therapeutics and interventions for EMCC.
Task Force suggestions: EMCC should include the following: (1) mechanical ventilation, (2) IV fluid resuscitation, (3) vasopressor administration, (4) medication administration for specific disease states (eg, antimicrobials and antidotes), (5) sedation and analgesia, and (6) select practices to reduce adverse consequences of critical illness and critical care delivery. Also, all hospitals with ICUs should prepare to deliver EMCC for a daily critical care census at three times their usual ICU capacity for up to 10 days.
Discussion:
By using the Task Force suggestions for EMCC, communities may better prepare to deliver augmented critical care in response to disasters. In light of current mass critical care data limitations, the Task Force suggestions were developed to guide preparedness but are not intended as strict policy mandates. Additional research is required to evaluate EMCC and revise the strategy as warranted.
Key Words: critical care surge capacity ? disaster medicine ? influenza pandemic ? mass casualty medical care ? medical surge capacity
---------
-
(1d) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity*
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Lewis Rubinson, MD, PhD; John L. Hick, MD; J. Randall Curtis, MD, MPH, FCCP; Richard D. Branson, MS, RRT; Suzi Burns, RN, MSN, RRT; Michael D. Christian, MD; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Daniel Talmor, MD, MPH, FCCP; Brian Erstad, PharmD; Justine Medina, RN, MS and James A. Geiling, MD, FCCP
* From the University of Washington (Dr. Rubinson), Seattle, WA; Hennepin County Medical Center (Dr. Hick), Minneapolis, MN; Harbor View Medical Center (Dr. Curtis), Seattle, WA; University of Cincinnati (Mr. Branson), Cincinnati, OH; University of Virginia (Ms. Burns), Charlottesville, VA; Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; Beth Israel Deaconess Medical Center (Dr. Talmor), Boston, MA; University of Arizona (Dr. Erstad), Tucson, AZ; American Association of Critical Care Nurses (Ms. Medina), Aliso Viejo, CA; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), Hanover, NH. A list of Task Force members is given in the Appendix.
Correspondence to: Lewis Rubinson, MD, PhD, University of Washington, Harborview Medical Center, Campus Box 359762, 325 Ninth Ave, Seattle, WA 98104; e-mail: rubinson@u.washington.edu
Background:
Mass numbers of critically ill disaster victims will stress the abilities of health-care systems to maintain usual critical care services for all in need. To enhance the number of patients who can receive life-sustaining interventions, the Task Force on Mass Critical Care (hereafter termed the Task Force) has suggested a framework for providing limited, essential critical care, termed emergency mass critical care (EMCC). This article suggests medical equipment, concepts to expand treatment spaces, and staffing models for EMCC.
Methods:
Consensus suggestions for EMCC were derived from published clinical practice guidelines and medical resource utilization data for the everyday critical care conditions that are anticipated to predominate during mass critical care events. When necessary, expert opinion was used.
Task Force major suggestions:
The Task Force makes the following suggestions: (1) one mechanical ventilator that meets specific characteristics, as well as a set of consumable and durable medical equipment, should be provided for each EMCC patient; (2) EMCC should be provided in hospitals or similarly equipped structures; after ICUs, postanesthesia care units, and emergency departments all reach capacity, hospital locations should be repurposed for EMCC in the following order: (A) step-down units and large procedure suites, (B) telemetry units, and (C) hospital wards; and (3) hospitals can extend the provision of critical care using non-critical care personnel via a deliberate model of delegation to match staff competencies with patient needs.
Discussion:
By using the Task Force suggestions for adequate supplies of medical equipment, appropriate treatment space, and trained staff, communities may better prepare to deliver augmented essential critical care in response to disasters.
Key Words: disaster medicine ? influenza pandemic ? mass casualty medical care ? medical surge capacity
---------
-
(1e) [ABSTRACTS, RESEARCH, PANDEMIC PREPAREDNESS] Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care*
From a Task Force for Mass Critical Care Summit Meeting, January 26?27, 2007, Chicago, IL
Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Michael D. Christian, MD, FRCPC; Nancy N. Dubler, LLB; Christian E. Sandrock, MD, MPH, FCCP; John L. Hick, MD; Tia Powell, MD; James A. Geiling, MD, FCCP; Dennis E. Amundson, CAPT, MC, USN, FCCP; Tom E. Baudendistel, MD; Dana A. Braner, MD; Mike A. Klein, JD; Kenneth A. Berkowitz, MD, FCCP; J. Randall Curtis, MD, MPH, FCCP and Lewis Rubinson, MD, PhD
* From Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Montefiore Medical Center (Ms. Dubler), New York, NY; University of California, Davis (Dr. Sandrock), Davis, CA; Hennepin County Medical Center (Dr. Hick), Minneapolis, MN; New York State Task Force on Life and the Law (Dr. Powell and Mr. Klein), New York, NY; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), Hanover NH; Naval Medical Center (Dr. Amundson), San Diego, CA; California Pacific Medical Center (Dr. Baudendistel), San Francisco, CA; Oregon Health and Sciences Center (Dr. Braner), Portland, OR; VHA National Center for Ethics in Health Care and the New York University School of Medicine (Dr. Berkowitz), New York, NY; Harbor View Medical Center (Dr. Curtis), Seattle, WA; University of Washington (Dr. Rubinson), Seattle, WA. A list of Task Force members is given in the Appendix.
Correspondence to: Asha Devereaux, MD, MPH, 1224 Tenth St, #205, Coronado, CA 92118; e-mail: ADevereaux@pol.net
Background:
Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources.
Task Force suggestions:
In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.
Key Words: critical care ? disaster ? ethics ? health-care rationing ? health-care worker ? palliative medicine ? posttraumatic stress ? triage
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