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August 14, 2009
H1N1 ICU Triage Rules: Who Lives?
By Peter Laird, MD
In early April of this year, the first reports of a new flu hit the news. Slowly over a period of weeks, the reality came home that the world was dealing with its first influenza pandemic since 1968. The fear of a repeat of the deadly 1918 Spanish Flu were mitigated by the reports that the vast majority of infected patients had a mild clinical course with complete recovery. However, the reports aren't entirely accurate and the 2009 H1N1 pandemic flu has characteristics similar in many aspects to the 1918 flu. These worrying facts, including continued spread during the summer months and severe pneumonia affecting a number of young and healthy patients, is why the H1N1 virus should be taken very seriously.
The World Health Organization, CDC and other US Federal organizations have spent several years preparing a coordinated response to a pandemic disease. These preparations began in earnest under the Bush administration after the rapid spread and high case fatality rate of the SARS corona virus and the emergence of the high CFR H5N1 bird flu virus. It has always been the case that a deadly virus could arise and devastate the world's population as it did at the beginning of the 20th century so we always should have been planning. However, it was the recent emergence of pandemic potential viruses that truly spurred planning.
Then came H1N1. Television and online media outlets give us regular updates on how the current H1N1 pandemic flu is affecting people in America and most especially in the southern hemisphere as their flu season continues unabated. The planning and organization at the national level has been coordinated with every state in the union with many stockpiling large amounts of personal protective equipment and Tamiflu which remains effective against this virus. However, it is unclear how effective this national and state wide planning has been implemented on the local level and especially in vulnerable populations such as dialysis patients.
Northwest Kidney Centers is a model for participation in local and statewide pandemic planning as well as preparing to prevent the spread of H1N1 among both their staff and their patients. I suspect that few dialysis providers are as well prepared to weather this storm coming soon to our dialysis units. Bill has sought diligently to find any data showing how severe H1N1 affects renal patients, but to date the CDC has not been forthcoming with all of the current case fatality distribution of risk factors. Much is still unknown on how many we can expect to be infected as well as how many of those will have a severe reaction. However, planning best practices requires us to consider dire scenarios. For people on dialysis we should understand how the entities we rely on, e.g. doctors, dialysis providers, hospitals, will respond to a worst case.
For instance, few people are aware of some of the Federal guidelines for our hospitals should a major pandemic overcome the hospital surge capacity. In the event that our hospital capacity is overwhelmed tough decisions will have to be made. Triage guidelines have been developed and accepted widely as a strategy for resource allocation in times of severe shortages. These widely accepted guidelines include exclusion of care categories. In a mass casualty situation, hard decisions are made on resource allocation that would never be made in ordinary times. In a flu pandemic emergency this would mean less care for those patients with dim survival prospects even with maximal care.
An example can be found in this California Department of Health Services draft discussion, Guidelines Regarding the Transition from Patient-Based to Population-Based Outcomes (PDF link):
When a physician graduates from medical school, he / she swears to an oath that embodies the ethics and ideals of Hippocrates, the acknowledged father of modern medicine. Translated from the traditional Greek version, the Hippocratic Oath emphatically states that a physician should "Above all, do no harm" to the patients he / she serves. An excerpt from this oath reads, "I will remember that I remain a member of society, with special obligations to all my fellow human beings." In the current state of medicine, each licensed provider of care has an overarching obligation to treat every individual patient to the best of his or her abilities. . .
Surge capacity planning for such resource poor environments must therefore consider a departure from the individual patient-based outcomes that physicians have been long conditioned to uphold in favor of an approach that saves the most lives. In other words, 'clinicians will need to balance the obligation to save the greatest possible number of lives against that of the obligation to care for each single patient.
...
A healthcare provider may determine that an individual will not receive care, or that care currently being provided to an individual will be discontinued or withdrawn, based on the criteria identified in Section V below. Examples of care that may be denied or discontinued or withdrawn in order to allocate limited resources in accordance with the criteria identified in Section V, include but are not limited to ventilator support, antibiotics, hydration and life-sustaining nutritional support, ICU and other facility beds and supplies, and blood.
...
Exclusion Criteria for Ventilator Access*
Cardiac arrest: unwitnessed arrest, recurrent arrest, arrest unresponsive to standard measures; Trauma-related arrest
Metastatic malignancy with poor prognosis
Severe burn: body surface area >40%, severe inhalation injury
End-stage organ failure:
Cardiac: NY Heart Association class III or IV
Pulmonary: severe chronic lung disease with FEV1** < 25%
Hepatic: MELD*** score > 20
Renal: dialysis dependent
Neurologic: severe, irreversible neurologic event/condition with high expected mortality
*Adapted from OHPIP guidelines
** Forced Expiratory Volume in 1 second, a measure of lung function
*** Model of end stage liver disease
These ICU pandemic triage rules could come into play if the current H1N1 2009 pandemic causes widespread and severe illness.
What the California DOH is contemplating is the reality of population outcome based pandemic planning and the exclusion criteria that could come to be. Knowing these policies could come into effect is what motivated Bill to be concerned about emergency planning. Given these policies, dialysis patients have to stay away from hospitals during a pandemic. That's the insight that has fueled Bill's advocacy. If every dialysis center was as prepared to maintain operations as the Northwest Kidney Centers I would be far less concerned. Unfortunately most patients and staff do not have access to Tamiflu or even personal protective equipment (PPE). Unfortunately current preparations rely on this being a mild event. If this should instead develop into a severe pandemic outbreak, closer to 1918 that to 1968, then the nation will have its first widespread experience with this new population based medical ethics.
My main hope is that the current H1N1 flu will remain mild. I pray that the majority of cases will be mild and our medical infrastructure can handle the demand on their services. I pray that widespread shortages remain theoretical. DSEN's pandemic flu posts promoting pandemic planning is an ongoing effort in the hope that dialysis providers will take pandemic flu planning seriously. People on dialysis are at tremendous risk in this and any other unmitigated virus outbreak in the future. Providers have an obligation to take preparation seriously, which means taking dire scenarios seriously.
Dialysis patients need to be able to feed themselves if their dialysis schedule is interrupted. You need to have at least a weeks worth of the Emergency Diet. You need to have the ability to take your blood pressure, your temperature and your weight. Dialysis patients, if they can, should obtain personal protective equipment and further, discuss with their nephrologist and dialysis providers what steps have been taken to protect their patients.
It is certainly more prudent to be prepared than to be caught short in an emergency situation, it is a routine adult responsibility.
H1N1 ICU Triage Rules: Who Lives?
By Peter Laird, MD
In early April of this year, the first reports of a new flu hit the news. Slowly over a period of weeks, the reality came home that the world was dealing with its first influenza pandemic since 1968. The fear of a repeat of the deadly 1918 Spanish Flu were mitigated by the reports that the vast majority of infected patients had a mild clinical course with complete recovery. However, the reports aren't entirely accurate and the 2009 H1N1 pandemic flu has characteristics similar in many aspects to the 1918 flu. These worrying facts, including continued spread during the summer months and severe pneumonia affecting a number of young and healthy patients, is why the H1N1 virus should be taken very seriously.
The World Health Organization, CDC and other US Federal organizations have spent several years preparing a coordinated response to a pandemic disease. These preparations began in earnest under the Bush administration after the rapid spread and high case fatality rate of the SARS corona virus and the emergence of the high CFR H5N1 bird flu virus. It has always been the case that a deadly virus could arise and devastate the world's population as it did at the beginning of the 20th century so we always should have been planning. However, it was the recent emergence of pandemic potential viruses that truly spurred planning.
Then came H1N1. Television and online media outlets give us regular updates on how the current H1N1 pandemic flu is affecting people in America and most especially in the southern hemisphere as their flu season continues unabated. The planning and organization at the national level has been coordinated with every state in the union with many stockpiling large amounts of personal protective equipment and Tamiflu which remains effective against this virus. However, it is unclear how effective this national and state wide planning has been implemented on the local level and especially in vulnerable populations such as dialysis patients.
Northwest Kidney Centers is a model for participation in local and statewide pandemic planning as well as preparing to prevent the spread of H1N1 among both their staff and their patients. I suspect that few dialysis providers are as well prepared to weather this storm coming soon to our dialysis units. Bill has sought diligently to find any data showing how severe H1N1 affects renal patients, but to date the CDC has not been forthcoming with all of the current case fatality distribution of risk factors. Much is still unknown on how many we can expect to be infected as well as how many of those will have a severe reaction. However, planning best practices requires us to consider dire scenarios. For people on dialysis we should understand how the entities we rely on, e.g. doctors, dialysis providers, hospitals, will respond to a worst case.
For instance, few people are aware of some of the Federal guidelines for our hospitals should a major pandemic overcome the hospital surge capacity. In the event that our hospital capacity is overwhelmed tough decisions will have to be made. Triage guidelines have been developed and accepted widely as a strategy for resource allocation in times of severe shortages. These widely accepted guidelines include exclusion of care categories. In a mass casualty situation, hard decisions are made on resource allocation that would never be made in ordinary times. In a flu pandemic emergency this would mean less care for those patients with dim survival prospects even with maximal care.
An example can be found in this California Department of Health Services draft discussion, Guidelines Regarding the Transition from Patient-Based to Population-Based Outcomes (PDF link):
When a physician graduates from medical school, he / she swears to an oath that embodies the ethics and ideals of Hippocrates, the acknowledged father of modern medicine. Translated from the traditional Greek version, the Hippocratic Oath emphatically states that a physician should "Above all, do no harm" to the patients he / she serves. An excerpt from this oath reads, "I will remember that I remain a member of society, with special obligations to all my fellow human beings." In the current state of medicine, each licensed provider of care has an overarching obligation to treat every individual patient to the best of his or her abilities. . .
Surge capacity planning for such resource poor environments must therefore consider a departure from the individual patient-based outcomes that physicians have been long conditioned to uphold in favor of an approach that saves the most lives. In other words, 'clinicians will need to balance the obligation to save the greatest possible number of lives against that of the obligation to care for each single patient.
...
A healthcare provider may determine that an individual will not receive care, or that care currently being provided to an individual will be discontinued or withdrawn, based on the criteria identified in Section V below. Examples of care that may be denied or discontinued or withdrawn in order to allocate limited resources in accordance with the criteria identified in Section V, include but are not limited to ventilator support, antibiotics, hydration and life-sustaining nutritional support, ICU and other facility beds and supplies, and blood.
...
Exclusion Criteria for Ventilator Access*
Cardiac arrest: unwitnessed arrest, recurrent arrest, arrest unresponsive to standard measures; Trauma-related arrest
Metastatic malignancy with poor prognosis
Severe burn: body surface area >40%, severe inhalation injury
End-stage organ failure:
Cardiac: NY Heart Association class III or IV
Pulmonary: severe chronic lung disease with FEV1** < 25%
Hepatic: MELD*** score > 20
Renal: dialysis dependent
Neurologic: severe, irreversible neurologic event/condition with high expected mortality
*Adapted from OHPIP guidelines
** Forced Expiratory Volume in 1 second, a measure of lung function
*** Model of end stage liver disease
These ICU pandemic triage rules could come into play if the current H1N1 2009 pandemic causes widespread and severe illness.
What the California DOH is contemplating is the reality of population outcome based pandemic planning and the exclusion criteria that could come to be. Knowing these policies could come into effect is what motivated Bill to be concerned about emergency planning. Given these policies, dialysis patients have to stay away from hospitals during a pandemic. That's the insight that has fueled Bill's advocacy. If every dialysis center was as prepared to maintain operations as the Northwest Kidney Centers I would be far less concerned. Unfortunately most patients and staff do not have access to Tamiflu or even personal protective equipment (PPE). Unfortunately current preparations rely on this being a mild event. If this should instead develop into a severe pandemic outbreak, closer to 1918 that to 1968, then the nation will have its first widespread experience with this new population based medical ethics.
My main hope is that the current H1N1 flu will remain mild. I pray that the majority of cases will be mild and our medical infrastructure can handle the demand on their services. I pray that widespread shortages remain theoretical. DSEN's pandemic flu posts promoting pandemic planning is an ongoing effort in the hope that dialysis providers will take pandemic flu planning seriously. People on dialysis are at tremendous risk in this and any other unmitigated virus outbreak in the future. Providers have an obligation to take preparation seriously, which means taking dire scenarios seriously.
Dialysis patients need to be able to feed themselves if their dialysis schedule is interrupted. You need to have at least a weeks worth of the Emergency Diet. You need to have the ability to take your blood pressure, your temperature and your weight. Dialysis patients, if they can, should obtain personal protective equipment and further, discuss with their nephrologist and dialysis providers what steps have been taken to protect their patients.
It is certainly more prudent to be prepared than to be caught short in an emergency situation, it is a routine adult responsibility.
