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EMERGENCY MASS CRITICAL CARE

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					EMERGENCY MASS
 CRITICAL CARE

          Lewis Rubinson MD, PhD
            County Health Officer
     Deschutes County Health Department

Division of Pulmonary and Critical Care Medicine
              Bend Memorial Clinic
                   Bend, OR
          HUMAN CASES H5N1
              2004-2005
Most people are critically ill
   – Respiratory failure > 70%
   – Shock
   – Acute renal failure 10-29%


Case fatality rate ~ 52%
   – Most deaths from refractory respiratory failure


In US, pts with similar severity of illness are
  managed in ICUs
     CRITICAL CARE DEMAND
1. Number of critically ill patients
   – ?? availability and effectiveness of countermeasures
   – Uncertain virulence of strain with human-to-human
     transmission

2. Rate of development of critical illness
   – Time from hosp to resp failure:         < 2 days



3. Duration of critical illness
   – Time from hosp to death:                4-30 days
     (most cohorts median > 1 week)
 LIMITED ICU SURGE CAPACITY
87,400 ICU beds in non-federal US hospitals
   – ICU occupancy 65-80 %

Breadth of ICU meds and equipment create
  financial barriers to building reserve ICUs
   – Logistical difficulties of using reserve ICU and need
     for equipment maintenance further barriers

Shortages of critical care nurses, pharmacists,
  respiratory therapists and intensivists in most
  communities
   – > 10% of ICUs have beds closed due to nursing
     shortage
         MOST CRITICALLY ILL
          PEOPLE SURVIVE
Clinical    Usual ICU
Condition    Survival   Disaster Situation
ARDS        40-65 %
                        Patients unable to
                        receive mechanical
Severe        73 %
                        ventilation and/or
Sepsis
                        hemodynamic
                        support are likely to
Septic        50 %      die.
Shock
       IF LOCAL ICU CAPACITY
           IS OVERWHELMED
Current hospital operational plans (canceling elective
  surgeries, staff recall, etc) could augment critical care
  capacity by 20-50% of hospital total ICU capacity

Critical care evacuation may be limited or slow
   – Unaffected hospitals may not accept transfers.
       • Economic considerations
       • Fear
       • Potential to be impacted in future by outbreak
   – Infection control issues and fear may hinder patient transport


Deployable medical teams are not designed or prepared to
  augment critical care capacity
What to do when the number of
critically ill patients far exceeds
traditional hospital critical care
 capacity and evacuation is not
     immediately available?
                   OPTIONS
1. Provide usual ICU services on a first-come
   first-served basis.

2. Stop providing critical care services.


3. Plan and prepare for usual ICU services for all
   additional patients.

4. Modify standards of critical care to provide
   limited but high-yield critical care interventions
   and processes for many additional patients.
            EMERGENCY MASS
             CRITICAL CARE
Emergency changes in:
  1)   Spectrum of critical care interventions
  2)   Triage
  3)   Staffing
  4)   Medical equipment
  5)   Clinical trials

Provide circumscribed set of key critical care
   interventions to many patients rather than
   maximal critical care to far fewer

Derived from recommendations of a working group
   of 33 North American experts
WORKING GROUP ON EMERGENCY
    MASS CRITICAL CARE
Critical Care               Biosecurity                Bioethics
Edward Abraham, MD          Luciana Borio, MD          Nancy Dubler, LLB
Richard Branson, RRT, MS    D A Henderson, MD, MPH     Ruth Faden, PhD
Kathryn Brush, RN, MS       Thomas Inglesby, MD
James Cushman, MD           Jennifer Nuzzo, SM
J Christopher Farmer, MD    Tara O’ Toole, MD, MPH     Disaster Medicine
Mitchell Fink, MD           Lewis Rubinson, MD, PhD    Michael Allswede, DO
Leonard Hudson, MD                                     Dan Hanfling, MD
Stephen Lapinsky, MB, MSc   Local Public Health        Kevin Yeskey, MD
Margaret Parker, MD         Katherine Uraneck, MD
Thomas Stewart, MD
Daniel Talmor, MD, MPH      DHHS                       Hospital Admin.
                            Andrea Argabrite, FNP MS   Mark Ackermann
Infection Control/ ID       Steven Bice                Richard Waldhorn, MD
John Bartlett, MD           Robert Claypool, MD
Allison McGeer, MD          Sally Phillips RN, PhD
Andrew Streifel, MPH        Matthew Tarosky, Pharm-D
    Which critical care
 interventions should be
provided if resources are
limited and usual critical
care cannot be provided
      to all in need?
         FREQUENTLY USED
         ICU INTERVENTIONS
Intra-aortic counter-pulsation device
Continuous renal replacement therapy
ICP monitoring
High-frequency oscillatory ventilation
Activated protein C infusion
Conventional mechanical ventilation
Vasopressor infusion
Large volume blood product transfusions
Intra-arterial blood pressure monitoring
 PRIORITIZING CRITICAL CARE
       INTERVENTIONS
1. Supports the organ systems most likely to
   cause death

2. Demonstrated effectiveness or best
   professional judgment to improve survival in
   similar clinical conditions

3. Do not require prohibitively expensive
   equipment
  –   Not staff or resource intensive
  EMERGENCY MASS CRITICAL
    CARE INTERVENTIONS
Mechanical ventilation
  – Basic mode(s)


Hemodynamic support
  – IV fluids, vasopressor(s)


Set of prophylactic interventions
  – Thromboembolism prophylaxis, elevation of head of
    bed and ? GI prophylaxis
    AUGMENTING POSITIVE
  PRESSURE VENTILATION (PPV)
Reserve sophisticated full-feature
 ventilators
                                                     Increasing
                                                     numbers of
Vendor rental supply                                   victims
   – Limited data regarding quantities available,     needing
     especially during large event with many          PPV and
     requesting hospitals                            evacuation
                                                         not
                                                    immediately
Anesthesia machines                                   possible
   – Adequate short-term option, but limited
     quantities and cannot be repurposed for
     long response


Alternative ventilation options
     STRATEGIC NATIONAL
    STOCKPILE VENTILATORS
• Thousands of
  ventilators
   – Not enough for serious
     pandemic


• Prioritization for
  distribution to many
  hospitals in need
  remains uncertain

• NO OXYGEN !
       IDEAL PPV DEVICE FOR
       MASS CASUALTY EVENT
1. Adequate oxygenation and ventilation for all patient types
   (including pediatrics) and categories of events
   – Ability to mechanically ventilate patient for several days to weeks
2. Efficient use of medical gas
   – May be key limiting resource for mass casualty event
3. Easy to use
   – Easy to set up, start, and troubleshoot
   – Familiar modes of ventilation
4. Maximal patient safety
   – Monitoring of parameters and alarm notification
5. Maximal health care worker safety
   – Remote monitoring
   – Infection control
6. Battery or non-AC power source
   – Ruggedized
7. Inexpensive to purchase and maintain
                        PPV OPTIONS
   CATEGORY           CONSTANT        PEEP         COST       MAJOR LIMITATIONS
                       VT & VE?

Manual Device            No       External valve     $10      Person must be with pt at
                                                              all times. Potential for
                                                              variable delivery.

Automatic                No       No, Low levels   $50-1000   Failure to reach pressure
Resuscitator                      a consequence               results in continuous
                                  of operation.               inspiration. May rapidly
                                                              cycle with many conditions.
                                                              Person must be with pt at
                                                              all times.
EMS Transport            Yes      Usually with      $1500-    Very limited alarm
Ventilator                        external valve     3500     capabilities. Large O2
                                                              requirement.
Portable Ventilator      Yes      Yes 0-20 cm       $5000-    Some require medical gas
                                                    12,000    for operation (potential for
                                                              O2 requirement).
Full-feature             Yes      Yes, 0-30 cm      $9000-    Cost, complexity of use,
Ventilator                                          40,000    may have limited
                                                              portability.
 Triage and Rationing:
  Who should receive
Emergency Mass Critical
         Care?
       ICU TRIAGE IS COMMON




Goal is to identify patients unlikely to benefit from ICU care
For serious pandemic may need to prioritize critical care
among patients who would normally be considered to
possibly benefit from critical care
               TRIAGE OPTIONS
              DURING OUTBREAKS
1. “First-come, first-served”
    – Current critical care triage


2. Prioritization based on likelihood to benefit
    – Utilitarian “the greatest good for the greatest
      number”


3. Prioritization based on social worth


 Pesik N, et al. Annals of Emerg Med. 2001.
        PRIORITIZATION TO
      RECEIVE CRITICAL CARE
If many more seriously ill patients than critical care
   capacity, people should be triaged based on likelihood of
   benefiting from care

Trauma triage algorithms unlikely to predict mortality for
  medical, critically ill patients

Triage criteria should be consistent with disease course or
   similar clinical conditions
   – E.g. medical critically ill patients with hypoxemic respiratory
     failure

Establish broad categories of survival
   – E.g. Low, medium, high likelihood of death
     TRIAGE FOR EMERGENCY
       MASS CRITICAL CARE
Whatever criteria decided upon, should be
 established pre-event
   – Public input and comment


Criteria should be evaluated early in outbreak and
  revised with analysis of near-real time data

Criteria should be uniformly applied in region

Initiation, withholding and withdrawing of critical
   care.
   – All ill people, including those not infected with influenza should
     be evaluated.
         TRIAGE CRITERIA AND
      ALLOCATION OF RESOURCES
                                > 67 % HIGH




Critically Ill                 34-66 % MED
Patients
                                                 Cut-off for withholding
                                                 and withdrawing critical
                                                 care interventions

                               0-33 % LOW



                                              Adjust up or down
                 Predicted Survival
                                              based on resources
   CHALLENGES FOR CRITICAL
         CARE TRIAGE
1. Legal and medical liability issues

2. What is the trigger to start emergency mass critical
   care triage?

3. How does one prioritize critically ill patients for
   receiving medical care?
   –   How does one predict mortality in a reasonably accurate and
       rapidly obtainable manner with limited diagnostic
       requirements?


4. How do you know when to stop performing emergency
   mass critical care triage?
  Who should provide
Emergency Mass Critical
        Care?
          USUAL ICU STAFFING
Ideal ICU staffing
   – Critical care pharmacists, respiratory therapists,
     nurses, registered dietitians and intensivists

Low Nurse:Patient ratios associated with worse
  outcomes

Pharmacists’ participation on daily rounds reduce
  adverse drug events

Respiratory therapists are invaluable for
 maintenance and operation of airway and
 ventilation equipment
    STAFFING FOR EMERGENCY
      MASS CRITICAL CARE
May have a number of non-critical care staff
 available
   – Surgeons, anesthesiologists if elective surgeries
     cancelled
   – Non-critical care allied health professionals


--HOWEVER--

Complexities of critical care may limit effectiveness of
 non-critical care staff working independently.
      TIERED STAFFING:
Critical care staff collaborating
with non-critical care staff on all
            patients
           TIERED NURSING
Non-critical care nurses assigned primary
 responsibility for patient assessment
  – Documentation
  – Administration of medications
  – Bedside care (maintaining head of bed at 45°, moving
    pts to prevent pressure ulcers)
  – Real-time patient assessment
             TIERED NURSING
Critical care nurses can supervise and advise non-
  critical care nurses on critical care-specific
  issues
   – Vasopressor and sedation titration


Suggested ratio (depending on situation):
  1 non-critical care nurse to 2 pts; 3 non-critical
  care nurses collaborating with 1 critical care
  nurse
      TIERED NPs, PAs,MDs,DOs
Non-intensivists responsible for general care of
 patients.
  –   Initial response to changes in patients’ condition
  –   Documentation of care and care plan
  –   Most non-critical care medical issues
  –   Critical care issues after consultation with intensivist
      or implementing standardized order sets

Intensivists manage acute emergencies, ventilator-
  patient interaction (together with RTs), and
  consult on general critical care issues
    TIERED NPs, PAs,MDs,DOs
1 non-intensivist to 6 patients; 4 non-intensivists to
  1 intensivist

Non-intensivists should receive basic critical care
 training as part of disaster preparedness (e.g.
 HDM)

Standardized order sets
   – Reduce variability and errors of omission
   – Modify for specific disease (e.g. pandemic influenza,
     inhalational anthrax)
         STAFFING COMPARISON
Staff Category                   Usual ICU Care             Emergency Mass CC

Nurses
       Critical Care                      14                             4
       Non-CC                             0                             12


Intensivists
       Critical Care                      1                             0.5
       Non-CC                             0                              2

Assumes 12 patients, 24 hour period.
Assumes 1:2 nurse:patient ratio, 12 hour shifts, and one charge nurse per shift
        without a patient-care assignment.
Assumes 24-hour intensivist coverage
Tiered staffing can be applied
to respiratory therapists and
     pharmacists as well
Where should Emergency Mass
Critical Care be delivered when
 all usual critical care options
            are full?
  EMERGENCY MASS CRITICAL
     CARE IN HOSPITALS
PACU, ED provide only a handful of additional
 beds

Equipment, medical gases, isolation, and using
  tiered staff most safely and efficiently provided
  on concentrated hospital wards
   – Step-down units first, then general hospital wards
   – If prolonged disaster repurposing endoscopy, cath
     labs, and ORs less optimal

Non-hospital alternate care sites should be used
 for non-critically ill patients
          EMERGENCY MASS
         CRITICAL CARE BEDS
ICUs usually 5-15% of total inpatient beds

In past, hospitals have made approximately 20%
  inpatient beds available within 24 hours by
  recalling staff, canceling surgeries, expedited
  discharges

Can increase hospital total critical care capacity by
 2-4 fold if critically ill patients given admission
 priority
   – As outbreak unfolds, can likely increase critical care
     capacity 5-10 fold over existing ICU capacity.
 EQUIPMENT FOR EMERGENCY
    MASS CRITICAL CARE
Portable ventilators, anesthesia machines and/or
    full-feature ventilators
    –   Medical gas, suction

Pulse oximeter

Non-invasive blood pressure cuffs

Urine quantification device

IV administration equipment (hospitals may
    choose to have central venous catheters)
Learning during
  outbreaks
             RAPID LEARNING
Hospitals must have information technology
 capabilities for collecting clinical data on patients
 receiving emergency mass critical care.
   – Predictors of mortality and resource-use can modify
     triage algorithms

Clinical trials necessary to identify effective and
  ineffective treatments
   – For important critical care interventions, absolute
     mortality reduction is usually < 10%
   – Confounding by indication
                  EMERGENCY MASS
                   CRITICAL CARE
Emergency Changes              Assumptions:
Scope of critical care         Some critical care is better than
                                  no critical care
Critical care triage
                               Knowledge about usual critical
Staffing                          care interventions can guide
                                  prioritization of high yield
                                  interventions
Equipment

Clinical Trials

    Goal: provide the best possible outcomes for the
              greatest number of patients

				
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posted:11/23/2011
language:English
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