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BEST PRACTICES IN THE FACE OF SCARCITY DURING AN EMERGENCY
Public Health Connections Newsletter Sept. 2009
submitted by Jason Eberhart-Phillips, MD, MPH Kansas State Health Officer
Most of us take it for granted that in an emergency the local health care system will be able to respond with the best possible treatments, including the world?s most ad-vanced medical technology. We assume that whatever doctors require to save lives will always be available in ample supply when acute hospital care is called for, whether that is oxygen, IV fluids, medications or life-supporting mechanical ventilators.
But what might happen to patients caught in a major disaster, like a statewide flu pandemic, when the health care system is severely overloaded? How will the limited supply of hospital beds, services and supplies be allocated fairly and ethically in such an overwhelming public health emergency? These are questions that healthcare stakeholders are hammering out now in Kansas, under the guidance of Gianfranco Pezzino, senior fellow at the Kansas Health Institute. Working under a contract with KDHE, Dr. Pez-zino?s group is examining the ?paradigm shift? that would be necessary when the resources available to treat sick people suddenly fall short of the demand. Such a shift requires a new way of thinking at the height of an emergency. Instead of doing everything possible to save every life, doctors and other health professionals would need to allocate the limited resources they have to save as many lives as possible, through a process known as triage. ?Instead of treating the sickest or the most injured first, triage would focus on identifying and reserving im-mediate treatment for individuals who have a critical need for treatment and are likely to survive,? Dr. Pezzino writes in a report he is preparing as part of the project. ?This fundamental shift of focus from individual to mass health care is critical to achieve the goal of maximizing the number of lives saved.?
2
Such rationing of critical health care resources at a time of tremendous need must be done in a fair and clin-ically sound manner. The process for making decisions has to be transparent, trustworthy and grounded firmly in widely held ethical principles. Decisions about whom to treat aggressively should not be determined by the patient?s perceived social worth, ability to pay, or vague notions about the person?s ?quality of life.? On the contrary, decisions about whom to treat will have to be based on objective clinical evaluations, such as the sequential organ failure assessment (SOFA) score, which measures in a single number the function in the lungs, liver, brain and kidneys, as well as blood clotting and blood pressure. Patients whose SOFA scores indi-cate either a very high probability or a low probability of imminent death would not be admitted to critical care during the period of the emergency. In an ideal world, the modified protocols hospitals need to address likely scenarios of scarce resources would be worked out well in advance of any emergency where they would likely be used. Unfortunately, the pandemic of novel H1N1 influenza has arrived before such work was completed in Kansas. For now the pandemic flu has not overburdened the healthcare system in Kansas, but large numbers of cas-es in coming months could squeeze supplies of critical resources. Recent experience with H1N1 flu in the Southern Hemisphere tells us that while the overall number of hospitalized patients is relatively low, the propor-tion of such patients needing intensive care ? including mechanical ventilation ? is higher than expected from seasonal flu. Kansas must get ready, in case a sudden surge in disease swamps the available supply of ventila-tors and critical care resources here. For that reason a group of critical care specialists and other health professionals is coming together to ?fast track? a set of protocols for Kansas hospitals to use in the event that key resources become scarce. They expect to complete the task by November. With standard procedures for use in emergencies established right away by professional consensus, doctors and hospitals throughout the state will have the guidance they need to make the difficult decisions about the triage of patients, the use of certain equipment and the prioritization of services if the pandemic worsens. None of this work is easy. I thank Dr. Pezzino and the medical, legal and ethical advisors who are contribut-ing to this effort for asking the uncomfortable questions that need to be asked, and earnestly seeking workable answers.
Public Health Connections Newsletter Sept. 2009
submitted by Jason Eberhart-Phillips, MD, MPH Kansas State Health Officer
Most of us take it for granted that in an emergency the local health care system will be able to respond with the best possible treatments, including the world?s most ad-vanced medical technology. We assume that whatever doctors require to save lives will always be available in ample supply when acute hospital care is called for, whether that is oxygen, IV fluids, medications or life-supporting mechanical ventilators.
But what might happen to patients caught in a major disaster, like a statewide flu pandemic, when the health care system is severely overloaded? How will the limited supply of hospital beds, services and supplies be allocated fairly and ethically in such an overwhelming public health emergency? These are questions that healthcare stakeholders are hammering out now in Kansas, under the guidance of Gianfranco Pezzino, senior fellow at the Kansas Health Institute. Working under a contract with KDHE, Dr. Pez-zino?s group is examining the ?paradigm shift? that would be necessary when the resources available to treat sick people suddenly fall short of the demand. Such a shift requires a new way of thinking at the height of an emergency. Instead of doing everything possible to save every life, doctors and other health professionals would need to allocate the limited resources they have to save as many lives as possible, through a process known as triage. ?Instead of treating the sickest or the most injured first, triage would focus on identifying and reserving im-mediate treatment for individuals who have a critical need for treatment and are likely to survive,? Dr. Pezzino writes in a report he is preparing as part of the project. ?This fundamental shift of focus from individual to mass health care is critical to achieve the goal of maximizing the number of lives saved.?
2
Such rationing of critical health care resources at a time of tremendous need must be done in a fair and clin-ically sound manner. The process for making decisions has to be transparent, trustworthy and grounded firmly in widely held ethical principles. Decisions about whom to treat aggressively should not be determined by the patient?s perceived social worth, ability to pay, or vague notions about the person?s ?quality of life.? On the contrary, decisions about whom to treat will have to be based on objective clinical evaluations, such as the sequential organ failure assessment (SOFA) score, which measures in a single number the function in the lungs, liver, brain and kidneys, as well as blood clotting and blood pressure. Patients whose SOFA scores indi-cate either a very high probability or a low probability of imminent death would not be admitted to critical care during the period of the emergency. In an ideal world, the modified protocols hospitals need to address likely scenarios of scarce resources would be worked out well in advance of any emergency where they would likely be used. Unfortunately, the pandemic of novel H1N1 influenza has arrived before such work was completed in Kansas. For now the pandemic flu has not overburdened the healthcare system in Kansas, but large numbers of cas-es in coming months could squeeze supplies of critical resources. Recent experience with H1N1 flu in the Southern Hemisphere tells us that while the overall number of hospitalized patients is relatively low, the propor-tion of such patients needing intensive care ? including mechanical ventilation ? is higher than expected from seasonal flu. Kansas must get ready, in case a sudden surge in disease swamps the available supply of ventila-tors and critical care resources here. For that reason a group of critical care specialists and other health professionals is coming together to ?fast track? a set of protocols for Kansas hospitals to use in the event that key resources become scarce. They expect to complete the task by November. With standard procedures for use in emergencies established right away by professional consensus, doctors and hospitals throughout the state will have the guidance they need to make the difficult decisions about the triage of patients, the use of certain equipment and the prioritization of services if the pandemic worsens. None of this work is easy. I thank Dr. Pezzino and the medical, legal and ethical advisors who are contribut-ing to this effort for asking the uncomfortable questions that need to be asked, and earnestly seeking workable answers.