definitive care for the critically ill during a disaster swine flu disaster plan

Definitive Care For The Definitive Care For The Critically Ill During A DisasterCritically Ill During A Disaster

Swine FluSwine FluDisaster PlanDisaster Plan

Dr. Abd El-Baset M. Saleh, Dr. Abd El-Baset M. Saleh, MD, ACCP, AASMMD, ACCP, AASM

Lecturer of Chest Medicine, Mansoura UniversityLecturer of Chest Medicine, Mansoura University

Abdel Baset M. Saleh, Swine Flu Meeting, 5/5/2009


Making plans now will help you Making plans now will help you to be ready for the coming flu to be ready for the coming flu pandemic, which could last up pandemic, which could last up

to several monthsto several months

• Stuff.Stuff.• Staff.Staff.• ICU space to provide timely, usual ICU space to provide timely, usual

critical care, but if a mass critical care critical care, but if a mass critical care event were to occur tomorrow.event were to occur tomorrow.

Most countries have insufficient Most countries have insufficient critical carecritical care


What can we doWhat can we do


This meeting is intended toThis meeting is intended tointroduce disaster plan for introduce disaster plan for providing a coordinated and providing a coordinated and uniform response to mass critical uniform response to mass critical care.care.


1.1. Critical care preparedness and Critical care preparedness and response capabilities and limitations.response capabilities and limitations.

2.2. Suggested framework for critical care Suggested framework for critical care surge capacity.surge capacity.

3.3. Suggestion for minimal resources Suggestion for minimal resources ICUs will need for MCC.ICUs will need for MCC.

4.4. Suggested framework for allocation of Suggested framework for allocation of scarce critical care resources when cc scarce critical care resources when cc surge capacity remains insufficient to surge capacity remains insufficient to meet need. meet need.

The main 4 items of disaster plan:The main 4 items of disaster plan:

1.1. Stuff,Stuff, Medical equipment & supplies Medical equipment & supplies2.2. Staff,Staff, apporpriately trained personels apporpriately trained personels3.3. Space,Space, The physical location suitable The physical location suitable

for safe provision of CC.for safe provision of CC.

I. Current Critical Care I. Current Critical Care Response CapacityResponse Capacity



• Mechanical ventilators essential equipment of treatment of respiratory failure.

• Estimates of total number of ICU ventilators in Mansoura University Hospitals & Ministry of Health Hospitals

In USA • between 53.000 & 70.000 / 17-23 / 100.000• 105.000 35 / 100.000

• Reserve ventilators• CPAP

1. Stuff1. Stuff


• Proposals to train hundreds of volunteers to provide manual ventilation to patients during pandemic.


• Like many areas of health care, critical care Like many areas of health care, critical care units face shortages of various team units face shortages of various team members.members.

• In the past, staff shortages have not typically In the past, staff shortages have not typically been a major problem during disasters.been a major problem during disasters.

• In bioevents staff may fail to report for duty In bioevents staff may fail to report for duty for a variety of reasons.for a variety of reasons.

• Although volunteers often converge on Although volunteers often converge on disaster striken communities.disaster striken communities.

2. Staff 2. Staff


Critical care requires specific functionalities, Critical care requires specific functionalities, including:including:

• ElectricityElectricity• OxygenOxygen• SuctionSuction• Medical gasMedical gas• Monitoring equipmentMonitoring equipment• And physical space for equipment and And physical space for equipment and

patient managementpatient management

3. Space:3. Space:


A Framework for A Framework for Optimizing Surge Optimizing Surge

CapacityCapacity


• Every hospital with an ICU should plan and Every hospital with an ICU should plan and prepare to provide EMCC and should do so in prepare to provide EMCC and should do so in coordination with regional hospital planning coordination with regional hospital planning efforts. efforts.

• Hospitals with ICUs should plan and prepare Hospitals with ICUs should plan and prepare to provide EMCC every day of the response to provide EMCC every day of the response for a total critically ill patient census at least for a total critically ill patient census at least triple usual ICU capacity. triple usual ICU capacity.

• Hospitals should prepare to deliver EMCC for Hospitals should prepare to deliver EMCC for 10 days without sufficient external 10 days without sufficient external assistance. assistance.


• EMCC should include, when applicable, the EMCC should include, when applicable, the following: following: 1.1. Mechanical ventilationMechanical ventilation2.2. IV fluid resuscitationIV fluid resuscitation3.3. Vasopressor administrationVasopressor administration4.4. Antidote or antimicrobial administration for Antidote or antimicrobial administration for

specific diseasesspecific diseases5.5. Sedation and analgesiaSedation and analgesia6.6. Select practices to reduce adverse consequences Select practices to reduce adverse consequences

of critical illness and critical care deliveryof critical illness and critical care delivery7.7. Optimal therapeutics and interventions, such as Optimal therapeutics and interventions, such as

renal replacement therapy and nutrition for renal replacement therapy and nutrition for patients unable to take food by mouth, if warranted patients unable to take food by mouth, if warranted by hospital or regional preference. by hospital or regional preference.


• All communities should develop a graded All communities should develop a graded response plan for events across the response plan for events across the spectrum from multiple casualty to spectrum from multiple casualty to catastrophic critical care events. These catastrophic critical care events. These plans should clearly delineate what levels plans should clearly delineate what levels of modification of critical care practices of modification of critical care practices are appropriate for the different surge are appropriate for the different surge requirements. Use of EMCC should be requirements. Use of EMCC should be restricted to mass critical care events. restricted to mass critical care events.


Medical Resources for Medical Resources for Surge Capacity Surge Capacity


• EMCC requires one mechanical EMCC requires one mechanical ventilator per patient concurrently ventilator per patient concurrently receiving sustained ventilatory support. receiving sustained ventilatory support.


• Positive pressure ventilation equipment Positive pressure ventilation equipment purchased for surge capacity should at a purchased for surge capacity should at a minimum accomplish the following: minimum accomplish the following: 1.1. be able to oxygenate and ventilate most pediatric be able to oxygenate and ventilate most pediatric

and adult patients with either significant airflow and adult patients with either significant airflow obstruction or ARDSobstruction or ARDS

2.2. be able to function with low-flow oxygen and be able to function with low-flow oxygen and without high-pressure medical gaswithout high-pressure medical gas

3.3. accurately deliver a prescribed minute ventilation accurately deliver a prescribed minute ventilation when patients are not breathing spontaneouslywhen patients are not breathing spontaneously

4.4. have sufficient alarms to alert the operator to have sufficient alarms to alert the operator to apnea, circuit disconnect, low gas source, low apnea, circuit disconnect, low gas source, low battery, and high peak airway pressures. battery, and high peak airway pressures.


• To optimize medication availability and To optimize medication availability and safe administration:safe administration:1.1. Rules for medication substitutionsRules for medication substitutions2.2. Rules for safe dose or drug frequency Rules for safe dose or drug frequency

reductionreduction3.3. Rules for conversion from parenteral Rules for conversion from parenteral

administration to oral/enteral when possibleadministration to oral/enteral when possible4.4. Rules for medication restriction (eg, Rules for medication restriction (eg,

oseltamavir if in short supply during an oseltamavir if in short supply during an influenza pandemic)influenza pandemic)

5.5. Guidelines for medication shelf-life Guidelines for medication shelf-life extension. extension.


• EMCC should occur in hospitals or similarly EMCC should occur in hospitals or similarly designed and equipped structures (eg, mobile designed and equipped structures (eg, mobile medical facility designed for critical care medical facility designed for critical care delivery, veterinary hospital, or outpatient delivery, veterinary hospital, or outpatient surgical procedure center). After ICUs, surgical procedure center). After ICUs, postanesthesia care units, and emergency postanesthesia care units, and emergency departments reach capacity, hospital departments reach capacity, hospital locations for EMCC should be prioritized in locations for EMCC should be prioritized in the following orderthe following order1.1. intermediate care units, step-down units, and large intermediate care units, step-down units, and large

procedure suitesprocedure suites2.2. hospital wards. hospital wards.


•Nonmedical facilities should be Nonmedical facilities should be repurposed for EMCC only if disasters repurposed for EMCC only if disasters damage regional hospital infrastructure damage regional hospital infrastructure by making hospitals unusable, and if by making hospitals unusable, and if immediate evacuation to alternate immediate evacuation to alternate hospitals is not available. hospitals is not available.


• Principles for staffing models should include Principles for staffing models should include the following: the following: 1.1. patient care assignments for caregivers should be patient care assignments for caregivers should be

managed by the most experienced clinician managed by the most experienced clinician availableavailable

2.2. assignments should be based on staff abilities and assignments should be based on staff abilities and experienceexperience

3.3. delegation of duties that usually lie within the delegation of duties that usually lie within the scope of some workers’ practice to different health-scope of some workers’ practice to different health-care workers may be necessary and appropriate care workers may be necessary and appropriate under surge conditionsunder surge conditions

4.4. systematic efforts to reduce care variability, systematic efforts to reduce care variability, procedure complications, and errors of omission procedure complications, and errors of omission must be used when possible. must be used when possible.


A Framework for A Framework for Allocation of Scarce Allocation of Scarce Resources in Mass Resources in Mass

Critical Care Critical Care


•All hospitals must operate All hospitals must operate uniformly and cooperate in order to uniformly and cooperate in order to successfully implement a triage successfully implement a triage process when resources are scarce process when resources are scarce and/or unavailable. and/or unavailable.


• All attempts should be made by the health-All attempts should be made by the health-care facility to acquire scarce critical care care facility to acquire scarce critical care resources or infrastructure, or to transfer resources or infrastructure, or to transfer patients to other health-care facilities that patients to other health-care facilities that have the appropriate ability to provide care have the appropriate ability to provide care (state, national, and even international). (state, national, and even international). Critical care will be rationed only after all Critical care will be rationed only after all efforts at augmentation have been exceeded. efforts at augmentation have been exceeded. The Task Force assumes that EMCC has The Task Force assumes that EMCC has become exhausted and a Tier 6+ level has become exhausted and a Tier 6+ level has been attained or exceeded. been attained or exceeded.


• The Task Force offers a uniform approach to triaging The Task Force offers a uniform approach to triaging patients during allocation of scarce resources based patients during allocation of scarce resources based on objective and quantitative criteria with the on objective and quantitative criteria with the following underlying principles as a foundation for following underlying principles as a foundation for this process: this process: 1.1. Critical care will be rationed only after all efforts at Critical care will be rationed only after all efforts at

augmentation have been exceeded. augmentation have been exceeded. 2.2. Limitations on critical care will be proportional to the actual Limitations on critical care will be proportional to the actual

shortfall in resources. shortfall in resources. 3.3. Rationing of critical care will occur uniformly, be transparent, Rationing of critical care will occur uniformly, be transparent,

and abide by objective medical criteria. and abide by objective medical criteria. 4.4. Rationing should apply equally to withholding and Rationing should apply equally to withholding and

withdrawing life-sustaining treatments based on the principle withdrawing life-sustaining treatments based on the principle that withholding and withdrawing care are ethically that withholding and withdrawing care are ethically equivalent. equivalent.

5.5. Patients not eligible for critical care will continue to receive Patients not eligible for critical care will continue to receive supportive medical or palliative care. supportive medical or palliative care.


• The Task Force suggests that a triage officer The Task Force suggests that a triage officer and support team implement and coordinate and support team implement and coordinate the distribution of scarce resources. the distribution of scarce resources.

• The Task Force suggests a systematic, The Task Force suggests a systematic, retrospective review of the decisions of the retrospective review of the decisions of the triage team by a review committee. triage team by a review committee.

• Palliative care is a required component of Palliative care is a required component of mass critical care. mass critical care.


• The Task Force believes a strong commitment The Task Force believes a strong commitment to the ethical considerations outlined in the to the ethical considerations outlined in the article is necessary in implementation of the article is necessary in implementation of the triage process and allocation of scarce triage process and allocation of scarce resources. resources.

• Providers should be legally protected for Providers should be legally protected for providing care during the allocation of scarce providing care during the allocation of scarce resources in mass critical care when resources in mass critical care when following accepted protocols. following accepted protocols.

Thank

You

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