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Definitive Care for the Critically Ill During a Disaster |

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 FREE TO VIEW

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; Lewis Rubinson, MD, PhD
Author and Funding Information

Affiliations: *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



Chest. 2008;133(5_suppl):51S-66S. doi:10.1378/chest.07-2693
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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.

Figures in this Article

The Task Force for Mass Critical Care (hereafter called the Task Force) proposes use of emergency mass critical care (EMCC) to increase critical care surge capacity for mass critical care events (see “Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity” and “Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity”). However, even with use of EMCC, more patients may require critical care than can be provided with available resources. Limited medical resources may need to be shared or reallocated to other patients with a higher likelihood of survival. Issues that need further clarification include: Who should receive limited resources, and how should they be allocated? Should those with the highest risk of mortality receive intervention? How should their prognosis be determined? Who should make the allocation decisions? Under what conditions will caregivers who participate in reallocation of resources face civil and criminal penalties? This document provides a mechanism of triage and process for allocation of scarce resources in the event of a mass disaster when all resources are exhausted and not even EMCC can be provided for all.

Allocation and rationing of scarce critical care resources are legally, ethically, and emotionally complex. In the event of a catastrophic event, the lack of a plan to address these issues will result in the perception of unjust allocation of resources, or actual injustice may take place. Optimal allocation of scarce resources in a mass casualty event depends on the ability of public health authorities, government officials, institutional leaders, health-care professionals, and the public to embrace the paradigm shift from individual to population-based care, and will be best accomplished in advance of a disaster.12 The full details of the methods for this article have been described elsewhere (see “Summary of Suggestions From the Task Force on Mass Critical Care Summit”).

Suggestion 4.1:

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

In order to fairly distribute scarce critical care resources during mass casualties, the Task Force believes the following institutional elements form the necessary foundation of operations by which hospitals should function during an emotionally difficult time.

Government:

National, state, and local governments have an obligation to facilitate hospital planning, allocate intelligently, educate openly, and ensure that providers and institutions acting in good faith will not be penalized.

Community:

Appropriate risk communication and transparency of the planning process is not merely an institutional mandate, but rather a government responsibility that can be supported and facilitated by community leaders.3

Hospitals:

Preparedness requires anticipating not only the needs of patients, but also the needs of care providers. Health-care organizations have an obligation to provide the best care possible to patients under the circumstances, and a responsibility to protect their employees.4 Facilities must minimize harm to staff by doing the following: (1) providing appropriate personal protective equipment, (2) accumulating necessary medications and supplies, (3) changing the scope of practice and responsibilities to expand employee capacity to provide care, (4) training health-care workers for new tasks required by the disaster situation, and (5) establishing supervisory systems that provide necessary support during and after crisis situations.

Individuals:

Medical staff in their role as triage officers or as clinicians working with limited resources will be expected to change the paradigm of care. They will need to understand that in decisions made during the event, they must consider a duty to the population, as opposed to the individual.5 Triage of scarce resources is the most extreme among a range of options; therefore, training and familiarity with the triage and allocation process will be vital.

Although prioritization of health-care workers for influenza vaccine and antiviral treatment during a pandemic is advocated by the US Centers for Disease Control and Prevention6in order to maintain the workforce of the health-care system for the benefit of the community, it is unlikely that similar prioritization of such groups to receive critical care offers community benefit.7 After extensive consideration, the Task Force does not recommend preferential distribution of critical care resources for any population groups.

Suggestion 4.2:

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

The decision to initiate the triage algorithm and allocation of scarce resources should occur in conjunction with local and regional Medical Emergency Operations Command authority (usually within the public health department). Table 1 outlines the tiered system of critical care response levels. Tables 2and 3 delineate the necessary elements in order to initiate a triage process to allocate limited resources. Because disasters may be rapid and sudden, all of these elements may occur simultaneously and not sequentially. Figure 1 provides a visual representation of coordinated triage using the committee and support team process at a regional and/or state level. After the critical resource or infrastructure is replaced, the health-care entity in conjunction with the local and regional health authorities can return to the previous level of care.

Primary and Secondary Triage

Although the primary focus of this document is the triage of critical care resources (tertiary triage), it is essential to view the proposed triage process in the context of the system within which critical care operates rather than in isolation. A critically ill patient has several points of contact with the health-care system prior to reaching the ICU. Each contact point presents an opportunity to assess the patient and triage. When dealing with mass casualty situations, exercising these opportunities to assess and triage patients is essential in order to optimize flow through the system, in addition to protecting downstream resources from being overwhelmed and disabled.56

The first point of contact for most critically ill patients is the emergency medical system in the prehospital field. This is the point where primary triage (the first sorting) is conducted by emergency medical systems personnel. Given the environment, skill set of the health-care workers, and setting, the complexity of triage decisions that can be made during primary triage is limited. Triage decisions at this point must rely on a limited set of objective criteria that do not require any laboratory data or other investigations. This would most likely represent a subset of the exclusion criteria outlined in this article.

The second possible point of contact with the system is the emergency department, where secondary triage is conducted by emergency department physicians. The information available at this point is often still limited but some preliminary investigations or additional hospital information may be available, allowing more complex triage decisions to be made. Again, the triage criteria on which these decisions are based would be an expanded version of those used in the prehospital setting.

Tertiary triage is conducted within the hospital and deals with decisions such as disposition to the operating room in trauma scenarios or to critical care areas, as is the focus of this working group. Given that the focus of this working group is on tertiary triage, we do not provide any specific recommendations for primary and secondary triage.

Suggestion 4.3:

The Task Force offers a uniform approach to triaging patients during allocation of scarce resources based on objective and quantitative criteria with the following underlying principles as a foundation for this process: (1) critical care will be rationed only after all efforts at augmentation have been exceeded; (2) limitations on critical care will be proportional to the actual shortfall in resources; (3) rationing of critical care will occur uniformly, be transparent, and abide by objective medical criteria; (4) rationing should apply equally to withholding and withdrawing life-sustaining treatments based on the principle that withholding and withdrawing care are ethically equivalent8; and (5) patients not eligible for critical care will continue to receive supportive medical or palliative care.

This triage algorithm is designed to be objective, to be adaptable to regional supply and demand of resources, and to consider disease- or event-specific circumstances. Each region will have to assess and proactively adjust the process as necessary. This process may be imperfect but should serve as a sound foundation to fairly distribute scarce resources during mass critical care. The proposed triage algorithm is composed of three components: the inclusion criteria, the exclusion criteria, and prioritization of care.

Inclusion Criteria:

To be admitted to critical care during a mass critical care crisis, patients must require active critical care interventions (Fig 2 ). This is identical to the inclusion criteria suggested by Christian et al.9Therefore, patients requiring “observation only” should not be admitted to critical care while the triage algorithm is implemented.1012

Exclusion Criteria:

Patients will meet exclusion criteria when they have a very high risk of death, little likelihood of long-term survival, and a correspondingly low likelihood of benefit from critical care resources. When patients meet exclusionary criteria, critical care resources may be reallocated to other patients (Fig 2). There are two subcomponents of the exclusion criteria: (1) the Sequential Organ Failure Assessment (SOFA) score, and (2) the severity of chronic illness.

The SOFA score is used to assess acute inpatient severity of illness and is to be calculated daily (Table 4 ). Although several more rigorous scoring systems were reviewed (Table 5 ), the SOFA score was chosen for several reasons: (1) it primarily assesses daily organ function; (2) the ease of obtaining physiologic parameters; (3) the ease of calculating the SOFA score; (4) simple laboratory tests are used for scoring; and (5) its validation in a wide variety of critical care conditions.10,1318

To meet the exclusion criteria using the SOFA score, a patient has to have at minimum an 80% risk of mortality. The 80% risk was proposed by the Task Force to exclude patients who are imminently near death independent of the care they receive, and not exclude patients who may have a reasonable chance of survival. This mortality level can be reassessed and adjusted in the midst of a mass casualty, based on the severity of the demand placed on resources. Based on published evidence, the following SOFA criteria are highly likely to represent a mortality of at least 80%1726: (1) highest SOFA ≥ 15 at any time during the hospital admission1920; (2) mean SOFA score ≥ 5 for at least 5 days and with a SOFA trend that is either rising or flat19,2122; (3) any patient that has six or more organ failures at any time.18

The exclusion criteria for severe chronic illness has been described previously as the third category of exclusion criteria; this category includes life-limiting illnesses, such as end-stage congestive heart failure, end-stage COPD, and terminal liver disease.9 Patients should be excluded if they have any one of these exclusion criteria (Table 6 ).

Other algorithms have recommended that the likely duration of critical care need, also referred to as the minimum qualification for survival, should be used to define a limit on the amount of resources utilized by any given patient.5,9,27 Because the conditions under which the triage process will be triggered implies a severe limitation of resources, a single patient who remains in an ICU for an extended period may use resources that could save the lives of several other patients. This is an important point and must be evaluated in conjunction with the actual demand and shortages during the allocation process.

Prioritization of Patients:

Following application of the inclusion and exclusion criteria, patients should be prioritized in a ranking that utilizes the latest SOFA score and daily SOFA trend (Fig 2 ). Though objective, the SOFA score provides only limited information as to the eventual outcome for any given patient.19,21 Prioritization of these patients will also require the expertise and judgment of experienced triage officers using the severity of acute and/or chronic illness, prognosis, and projected duration of resource need. Based on this information, the triage officer and team will determine whether there is sufficient basis to warrant reallocating resources. Summarized, the compelling reasons for reallocating critical care resources away from any given patient(s) will include the following circumstances28: (1) patients who have the highest SOFA scores and/or a SOFA trend that is flat or rising over several days but do not yet meet formal SOFA exclusion criteria; (2) a high degree of inpatient acuity with a poor chance for survival, and a likely long duration of need for critical care resources; (3) a moderate degree of acuity but a prolonged duration of critical care resource need is expected; and (4) a severe underlying chronic illness that in conjunction with any of the above factors leads a decision maker to feel the prognosis is poor, and/or the patient’s likely duration of critical care resource need will be prolonged.

Suggestion 4.4:

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

Triage Officer:

There is no applicable model of mass triage resulting from an infectious event, and the data regarding triage and outcome in mass critical care are limited.1112,2932 However, the lessons from mass trauma disasters have proven the benefit of the triage officer (usually a highly experienced surgeon) who oversees the clinical activities at the time of the crisis. The triage officer is in charge, assesses all patients, assigns a level of priority for each, and directs attention to the highest-priority patients. The triage officer may also be in charge of logistics, such as patient transfers or availability of resources, but is often assigned an administrator/director for this purpose.3334 In larger centers, this individual may report to a superior who has a greater breadth of responsibility.3341 The desirable qualities of a triage officer include exceptional clinical expertise, outstanding leadership ability, and effective communication skills.34 He or she is expected to make decisions that benefit the greatest number of patients given potentially limited resources, even though these decisions may not necessarily be best for any individual patient.5,27,34,39,42 To optimize effective functioning in a crisis, the triage officer must be well prepared and trained in advance by means of disaster drills or simulation testing.27,34,4243

For the ICU, the triage officer will review all patients for inclusion and exclusion criteria, and facilitate discharge from critical care for patients no longer requiring it. The triage officer will evaluate daily all patients receiving critical care, and evaluate those requested to be considered for critical care as they arise. The triage officer will review necessary patient data by chart review and discussion with the clinical team if needed. The triage officer is not expected to examine patients, except under circumstances where this information may be crucial in reaching a triage decision. However, patients who have a significant change in clinical status (such as a cardiac arrest and resuscitation) may need to be reassessed more than once daily.

The triage officer has the ultimate responsibility and authority for making decisions as to which patients will receive the highest priority for receiving critical care, and is empowered to make decisions regarding reallocation of critical care resources. The triage officer will share decisions with the attending clinician, who will then inform affected patients and family members. The triage officers’ decisions are final and there will be no appeals process. This is consistent with recommendations regarding the function of the triage officer from the trauma literature.5,27,34,39,42

Triage Team Composition:

The team will be composed of an experienced critical care nurse, respiratory therapist, and/or clinical pharmacist. Their role as triage team members is to provide information to the triage officer and to help facilitate and support his/her decision-making process. A representative from hospital administration may also be a part of the team to help with organization resources and to serve as a liason with hospital leadership.

The triage officer and team members should function in shifts lasting no longer than 12 to 16 h. Therefore, there must be at least two shifts to fully staff the triage function. Triage officers may require nonclinical (secretarial or administrative) support personnel for their data-gathering activities, documentation, and record keeping. Their decisions and supporting documentation should be reported daily to hospital leadership.

Command Structure in Large Hospitals:

In larger facilities, it may be necessary to have more than one triage officer and team, with each officer/team assigned a designated ICU or hospital area. Each of the triage officers will then need to report to the Medical Operations Section Chief (Hospital Incident Command System) within the Hospital Incident Command Center (Fig 3) in order to maintain communication and coordinate resources, but retains autonomy in resource allocation to individual patients. This communication responsibility may be delegated to the administrative liaison, but the main function of assessing internal and external resources and interacting with government authorities falls to leadership in the hospital command center.

Documentation:

Maintaining transparency of the triage process is crucial, and the triage officer and team must document decisions regarding all patients assessed, whether care is limited, provided, or not provided. Table 7 highlights key points for the medical record.

Suggestion 4.5:

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

The review committee may be composed of experienced professionals who typically no longer provide direct care, such as the chief nursing officer, chief medical officer, chief respiratory therapy supervisor, infection control director, or legal counsel. We recommend a small group of no more than three individuals.

The purpose of the review committee is to bring to the attention of the triage officer any concerns about the application of the triage algorithm, providing a chance to reflect on these concerns in approaching future decisions. The review committee does not have the authority to change a decision made by the triage officer. According to the New York State Department of Health and New York State Task Force on Life and the Law,7 an appeals process could create the potential for unworkable delays in the midst of a crisis.

Suggestion 4.6:

Palliative care is a required component of mass critical care.

Under normal medical circumstances, symptom relief plays a complementary role to curative measures until it is decided to transition to palliation as the primary goal. In a mass disaster with limited life-sustaining resources, more individuals may be denied curative treatment and the primary treatment focus for them will shift to palliation. As occurred in the aftermath of Hurricane Katrina, health-care professionals may encounter difficult decisions as they try to relieve suffering.44 During challenging times, it is imperative to uphold the ethical commitment to alleviate discomfort without intentionally hastening death; euthanasia is not acceptable. Thus, it is mandatory that mass disaster preparation anticipates palliation for large numbers of individuals.

Once resources become limited and individuals enter a triage process, some patients will be allowed access to ongoing curative attempts, while others will be allocated to a comfort-only pathway. For both groups, care should include alleviation of discomfort. Detailed discussion of palliative care in the critically ill is beyond the scope of this article and can be found elsewhere.4550

Suggestion 4.7:

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

In order to approach the equitable allocation of scarce resources, the Task Force used the following ethical commitments to serve as a framework in establishing the preceding triage process (see below).

Limitation of Individual Autonomy:

The fair and just rationing of scarce resources requires public health decisions based on objective factors, rather than on the choice of individual leaders, providers, or patients. All individuals should receive the highest level of care given the resources available at the time.1

Transparency:

Governments and institutions have an ethical obligation to plan allocation through a process that is transparent, open, and publicly debated.30 Governmental honesty about the need to ration medical care justifies institutional and professional actions of withholding and withdrawing support from individual patients. These restrictive policies must be understood and supported by medical providers and the public, ideally with reassurances that institutions and providers will be acting in good faith and legally protected in their efforts.

Justice/Fairness:

The proposed triage process relies on the principle of maximization of benefit to the population served. The triage process treats patients equally based on objective, physiologic criteria, and when these criteria do not clearly favor a particular patient, “first come, first serve” rules will apply. The triage process addresses only those in the acute hospital setting in need of the scarce resource and will not apply to individuals with long-term reliance on the scarce resource (ie, long-term mechanical ventilation) in a long-term care facility prior to the mass casualty event. Communities and states may have different approaches to these patients.7 These individuals will be subject to the triage process should they need acute hospitalization, and resources will be allocated according to predefined criteria.

In order to ensure “procedural justice,” a standardized and equitable practice that conforms to the rules in place, any triage operation should be regularly and repeatedly evaluated to guarantee that the process has been followed fairly.51 This evaluation process will promote medical provider compliance; eliminate administrator, governmental, or physician overrule (special pleadings or “favors”); and facilitate consistency. Owing to the critical illness of patients and the limitations of the scarce resource(s), this evaluation process will need to be efficient and frequent. Direct appeals to the triage procedure may be impractical based on the urgency with which the allocation decision must be made. Individual physicians, administrators, or government officials should not be able to overrule a “good faith” decision made by a triage officer in compliance with the triage process. Because all patients will share the same pool of resources, the standard of care and triage process should apply to all patients, whether their condition is directly attributable to the mass casualty event or results from other underlying pathology or circumstances. If there is a challenge to procedural justice (ie, the process was not followed according to established criteria), then an appeal is indicated.

Suggestion 4.8:

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

Given the profound circumstances under which the algorithm would be activated, government action is needed to reassure providers and ensure consistent allocation of critical care resources across institutions.52The legal “standard of care” for medical malpractice arises from multiple sources (including evidence-based guidelines and customary medical practice) but is not generally a matter for government comment. This case should be different. As this algorithm is untested (and unprecedented outside of battlefield conditions), it might not guarantee that a judge or jury sitting in a malpractice case would exonerate a provider who acts in accordance with the suggested framework.53Nor can publication of a triage protocol block a criminal action where state law could be interpreted to criminalize provider compliance with the algorithm.54 Therefore, government endorsement of an algorithm process ideally would shield from liability practitioners and institutions acting in good faith.

Algorithm Compliance:

While a proposed algorithm may need to be revised once the conditions of the mass casualty event are better understood, such revisions should be made uniformly, ideally by an expert group at the state or federal level that can integrate emerging data into the algorithm. Ad hoc departures from the algorithm are ethically and legally unwise.

Establishing a triage algorithm as the standard of care during a mass casualty thus raises the issue of how to address noncompliance. It is essential to maintain the integrity of the triage process by preventing deviations from the algorithm, whether they deny treatment to patients who should receive it or provide or maintain treatment for patients who should not receive it. As a legal matter, if a triage algorithm constitutes the standard of care during a mass casualty event, then a patient “next in line” for a ventilator might pursue a claim against the provider for failure to treat. One proposed law, the Model State Emergency Health Powers Act, contemplates revising state medical licensing requirements during a public health emergency to compel provider compliance with emergency treatment requirements.55 Whether such a provision would be appropriate for enforcing the provision of critical care in accord with triage allocation of scarce resources warrants further discussion.

Although significant strides have been made in developing protocols for critical care triage in overwhelming mass casualty events, we remain in the very early developmental stages of preparing for triage situations. Much of the work done to date relies on the extrapolation of research findings not intended for use in triage, as well as expert opinion. Given the importance of the decisions being made in the triage process, further research is required in the domains of science, process, ethics, and law.

The first priority of research regarding the science of triage is to rigorously assess the operational and outcome validity of the currently suggested processes and protocols for triaging critically ill adults. Current clinical practice should be assessed to determine if the variables included in the suggested protocol are routinely recorded. Further, the impact of triage protocols must be studied both to determine the impact the protocol can have on making available resources and, most importantly, to thoroughly describe the consequences for those who are excluded from critical care. A variety of methods, including retrospective database analysis and computer modeling, can be used to answer various aspects of these questions.

Looking forward, there is a need to refine or redefine the illness severity scoring systems used in critical care triage protocols. The protocols proposed to date have used the SOFA score.89 The SOFA score is not ideal for triage in an emergency. Future research should attempt to validate the use of pulse oximetry in place of the Pao2. Further, it may be possible to identify a select subset of the variables included in the SOFA score that are predictive for use in triage, thus improving the ease of use of the scoring system in the setting of limited resources. Ideally, researchers will be able to develop an illness scoring system specifically for use in triage, incorporating only the information that will be readily available during an emergency, such as vital signs and other simple physiologic findings (eg, anuria, high oxygen requirements). The area most desperately in need of future study is pediatric triage, with few scoring systems available for critical care triage (Table 8 ).

Research opportunities exist to study all process aspects of triage protocols from conception through implementation and communication. The development of critical care triage protocols has been undertaken primarily by health-care professionals. Most of those involved in triage protocol development agree that there is a need for public consultation and input.9,5657 Studies assessing various mechanisms for soliciting manageable and meaningful public input would be of great value to those charged with developing triage protocols. In the past, triage has primarily been conducted in military or paramilitary structures with clear command and control processes.58 In the community, critical care triage will be conducted primarily by civilian health-care workers practicing in either the public or private sector. Further investigation is necessary to better understand how these cultures function during emergencies and what processes will be required to facilitate triaging. These investigations can employ various sociologic methodologies during both real disasters and disaster exercises. Finally, much work is still required to provide advice regarding the appropriate strategies to teach triage to those who will be doing it, communicating triage principles to the public, and finally, how best to communicate triage decisions to the families of the patients involved.

The final areas requiring further exploration are ethics and the law. Much work has already been done to outline the ethical considerations related to triage in general.57 However, this work must be reassessed to see if the same considerations apply to critical care triage, particularly in settings such as pandemics and in health-care systems in which preexisting inequities exist. The above discussion, although far from exhaustive, highlights the work that remains to be done to adequately prepare society for responding to mass casualty events. Clearly, with this amount of work still to be done, there is no time to be complacent or assume that the triage protocols outlined in this paper and elsewhere will be sufficient to address resource shortfalls in a mass casualty event.

Task Force Members in Alphabetical Order

Capt. Dennis Amundson, MD, FCCP, United States Navy, San Diego, CA; Capt. Michael B. Anderson, RN, MHA, CNAA, Department of Homeland Security, Washington, DC; Robert Balk, MD, Rush University Medical Center, Chicago, IL; Tom Baudendistel, MD, California Pacific Medical Center, San Francisco, CA; Ken Berkowitz, MD, VHA National Center For Ethics in Health Care, New York, NY; Michael Bourisaw, BS (Steering Committee), American College of Chest Physicians, Northbrook, IL; Dana Braner, MD, Doernbecher Children’s Hospital, Portland, OR; Suzanne Burns, RN, MSN, RRT, University of Virginia Health System, Charlottesville, VA; Michael D. Christian, MD, FRCPC (Steering Committee), University of Toronto, Toronto, ON, Canada; J. Randall Curtis, MD, MPH, Harborview Medical Center, Seattle, WA; Asha Devereaux, MD (Steering Committee), Sharp Coronado Hospital, San Diego, CA; Jeffery Dichter, MD (Steering Committee), Presbyterian Hospital, Albuquerque, NM; Nancy Dubler, LLB (Steering Committee), Montefiore Medical Center, Bronx, NY; Brian Erstad, PharmD (Steering Committee), University of Arizona Medical Center, Tucson, AZ; J. Christopher Farmer, MD, Mayo School of Graduate Medical Education, Rochester, MN; James Geiling, MD (Steering Committee), VA Medical Center, White River Junction, VT; Dan Hanfling, MD, Inova Fairfax Hospital, Falls Church, VA; John Hick, MD (Steering Committee), Hennepin County Medical Center, Minneapolis, MN; Capt. Ann Knebel, RN, DNSc, Department of Health and Human Services, Washington, DC; John Krohmer, MD, Department of Homeland Security, Washington, DC; Capt. Deborah Levy, PhD, MPH (Steering Committee), Centers for Disease Control and Prevention, Atlanta, GA; Henry Masur, MD, National Institutes of Health, Bethesda, MD; Justine Medina, RN, MS (Steering Committee), American Association of Critical Care Nursing, Aliso Viejo, CA; Nicki Pesik, MD (Steering Committee), Centers for Disease Control and Prevention, Atlanta, GA; Jim Pile, MD, The Cleveland Clinic, Cleveland, OH; Tia Powell, MD, New York State Task Force on Life and the Law, New York, NY; Lewis Rubinson, MD, PhD (Steering Committee), Harborview Medical Center, Seattle, WA; Christian Sandrock, MD, MPH, University of California-Davis, Davis, CA; Richard Serino, BS, Boston Emergency Medical Services, Boston, MA; Lewis Soloff, MD, New York City Department of Health and Mental Hygiene, New York, NY; Daniel Talmor, MD, MPH, Beth Israel Deaconess Medical Center, Boston, MA; Alvin Thomas Jr, MD, Howard University Hospital, Washington, DC; Richard Waldhorn, MD, University of Pittsburgh Medical Center, Baltimore, MD; Mark Woodhead, MD, Respiratory Infections-Manchester, Manchester, UK; Robert Wise, MD, The Joint Commission, Chicago, IL; Randy Wax, MD, Mount Sinai Hospital, Toronto, ON, Canada; Kevin Yeskey, MD (Steering Committee), Department of Health and Human Services, Washington, DC.

Abbreviations: EMCC = emergency mass critical care; SOFA = Sequential Organ Failure Assessment

The views expressed in this article do not represent the official positions or opinions of the Department of Veterans Affair or the Department of Defense, nor do they represent the views of the Centers for Disease Control and Prevention, the New York State government, or the Task Force on Life and the Law.

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Table 1. Response Tiers for Critical Care Surge Capacity*
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Table 1A. Continued
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Table 1B. Continued
* 

From Rubinson et al, “Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity” in this Supplement. MACC = multiagency coordinating center.

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Table 2. Potential Triggers To Initiate Triage Algorithm and Allocation of Resources at a Health-Care Facility Under EMCC
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Table 3. Conditions Required To Initiate a Triage Process To Allocate Scarce Resources
Figure Jump LinkFigure 1. Triage infrastructure: the optimal relationship between the state/regional central triage committee and the triage officer(s) at individual hospitals. The central triage committee must have situational awareness (knowledge of supply resources and demands on them), capacity to conduct research in order to develop then modify research protocols, and monitor triage outcomes. A bidirectional communication network between the central committee and hospitals in order to achieve situational awareness, monitor outcomes and communicate modifications to the triage protocols. At the individual hospitals, the triage officers(s) are supported by a staff/team.Grahic Jump Location
Figure Jump LinkFigure 2. Triage algorithm process: components 1 and 2, inclusion and exclusion criteria and prioritization of critical care resources.Grahic Jump Location
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Table 4. SOFA*
* 

How to calculate SOFA score: Each of the six components above is assigned a score based on a patient’s clinical or laboratory data; the total SOFA score is calculated by adding the score for each of the six components together. MAP = mean arterial pressure. Adapted from Moreno et al.18

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Table 5. Comparison of Four Severity of Illness Scoring Systems
* 

From Vincent et al.17

 

Adapted from Knaus et al.13

 

From Lemeshow et al14 Higgins et al.15

§ 

From LeGall et al.16

Table Graphic Jump Location
Table 6. Exclusion Criteria
Table Graphic Jump Location
Table 7. Medical Record Documentation Suggestions
Table Graphic Jump Location
Table 8. Pediatric Triage Topics in Need of Further Study

The authors gratefully appreciated the review of this article by Dr. Bryan Liang with the San Diego State University School of Public Health and Institute of Health Law Studies, California Western School of Law. Additionally, library assistance by Amanda Okandan, Dolly Bucsit, Amy Sharpe, and Laura Stubblefield was deeply appreciated.

Brannigan, M (2007) Deciding what is fair.Pract Bioethics2,1-2
 
Phillips, SJ, Knebel, A. Providing mass medical care with scarce resources: a community planning guide. 2006; Agency for Healthcare Research and Quality. Rockville, MD: publication 07–000.
 
Federal Emergency Management Agency.. National Incident Management System.2007,1-174 US Department of Homeland Security. Washington, DC:
 
Occupational Safety and Health Administration... Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. 2007; US Department of Labor. Washington, DC: publication 3328–05.
 
Burkle, FM Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster.Acad Emerg Med2006;13,1118-1129. [PubMed] [CrossRef]
 
Centers for Disease Control and Prevention.. Tiered use of inactivated influenza vaccine in the event of a vaccine shortage.MMWR Morb Mortal Wkly Rep2005;54,749-450. [PubMed]
 
Powell, T, Christ, KC, Brikhead, GS Allocation of ventilators in a public health disaster.Dis Med Pub Health Prep2008;2,20-26
 
Hick, J, O'Laughlin, DT Concept of operations for triage of mechanical ventilation in an epidemic.Acad Emerg Med2006;13,223-229. [PubMed]
 
Christian, MD, Hawryluck, L, Wax, RS, et al Development of a triage protocol for critical care during an influenza pandemic.Can Med Assoc J2006;175,1377-1381
 
Task Force of the American College of Critical Care Medicine.. Guidelines for intensive care unit admission, discharge, and triage.Crit Care Med1999;27,633-638. [PubMed]
 
Sinuff, T, Kahnamoui, K, Cook, DJ, et al Rationing critical care beds: a systematic review.Crit Care Med2004;32,1588-1597. [PubMed]
 
Joynt, GM, Gomersall, CD, Tan, P, et al Prospective evaluation of patients refused admission to an intensive care unit: triage, futility, and outcome.Intensive Care Med2001;27,1459-1465. [PubMed]
 
Knaus, WA, Draper, EA, Wagner, DP, et al APACHE II: a severity of disease classification system.Crit Care Med1985;13,818-828. [PubMed]
 
Lemeshow, S, Teres, D, Klar, J, et al Mortality probability models (MPM II) based on an international cohort of intensive care unit patients.JAMA1993;270,2478-2486. [PubMed]
 
Higgins, TL, Teres, D, Copes, WS, et al Assessing contemporary intensive care unit outcome: an updated mortality probability admission model (MPM0-III).Crit Care Med2007;35,827-835. [PubMed]
 
LeGall, JR, Lemeshow, S, Saulnier, F A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study.JAMA1993;270,2957-2963. [PubMed]
 
Vincent, JL, Moreno, R, Takala, J, et al The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure.Intensive Care Med1996;22,707-710. [PubMed]
 
Moreno, R, Vincent, JL, Matos, R, et al The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care-results of a prospective, multicentre study.Intensive Care Med1999;25,686-696. [PubMed]
 
Ferreira, FL, Bota, DP, Bross, A, et al Serial evaluation of the SOFA score to predict outcome in critically ill patients.JAMA2001;286,1754-1758. [PubMed]
 
Vincent, J, Mendonca, A, Cantraine, F, et al Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study.Crit Care Med1998;26,1793-1800. [PubMed]
 
Cabre, L, Mancebo, J, Solsona, JF, et al Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of sequential organ failure assessment scores in decision making.Intensive Care Med2005;31,927-933. [PubMed]
 
Oda, S, Hirasawa, H, Sugai, T, et al Comparison of sepsis-related organ failure assessment (SOFA) score and CIS (cellular injury score) for scoring of severity for patients with multiple organ dysfunction syndrome (MODS).Intensive Care Med2000;26,1786-1793. [PubMed]
 
Peres-Bota, D, Melot, C, Lopes-Ferreira, F, et al The multiple organ dysfunction score (MODS) versus sequential organ failure assessment (SOFA) score in outcome prediction.Intensive Care Med2002;28,1619-1624. [PubMed]
 
Kajdacsy-Balla, AC, Andrade, FM, Moreno, R, et al Use of the sequential organ failure assessment (SOFA) scoring.Crit Care Med2005;31,243-249
 
Arts, DG, de Keizer, NF, Vroom, MB, et al Reliability and accuracy of sequential organ failure assessment (SOFA) scoring.Crit Care Med2005;33,1988-1993. [PubMed]
 
Vincent, JL Organ dysfunction in patients with severe sepsis.Surg Infect2006;7,S69-S72
 
Burkle, FM Mass casualty management of a large-scale bioterrorist event: an epidemiologic approach that shapes triage decisions.Emerg Med Clin N Am2002;20,409-436
 
Hick, JL, Rubinson, L, O'Laughlin, DT, et al Clinical review: allocating ventilators during large-scale disasters-problems, planning, and process.Crit Care2007;11,217-226. [PubMed]
 
Cone, DC, Koenig, KL Mass casualty triage in the chemical, biological, radiological, or nuclear environment.Eur J Emerg Med2005;12,287-302. [PubMed]
 
Truog, RD, Brock, DW, Cook, DJ, et al Rationing in the intensive care unit.Crit Care Med2006;34,958-964. [PubMed]
 
Garrouste-Oregas, M, Montuclard, L, Timsit, JF, et al Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes.Intensive Care Med2003;29,774-781. [PubMed]
 
Simchen, E, Sprung, CL, Galai, N, et al Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds.Crit Care Med2004;32,1654-1661. [PubMed]
 
Kluger, Y, Mayo, A, Soffer, D Functions and principles in the management of bombing mass casualty incidents: lessons learned at the Tel-Aviv Souraski medical center.Eur J Emerg Med2004;11,329-334. [PubMed]
 
Baker, MS Creating order out from chaos: part II. Tactical planning for mass casualty and disaster response at definitive care facilities.Mil Med2007;172,237-243. [PubMed]
 
Jaslow, D Disasters: experience and planning.Eur J Emerg Med2005;12,263-264. [PubMed]
 
Kennedy, K, Aghababian, RV, Gans, L, et al Triage: techniques and applications in decision making.Ann Emerg Med1996;28,136-144. [PubMed]
 
Rhyne, CD Wake-up call.Top Emerg Med2005;27,180-182
 
Beekley, AC, Starnes, BW, Sebesta, JA Lessons learned from modern military surgery.Surg Clin North Am2007;87,157-184. [PubMed]
 
Domres, B, Koch, M, Manger, A, et al Ethics and triage.Prehosp Disaster Med2001;16,53-58. [PubMed]
 
Hoey, B, Schwab, CW Level 1 center triage and mass casualties.Clin Ortho Relat Res2004;422,23-29
 
Kluger, Y Bomb explosions in acts of terrorism: detonation, wound ballistics, triage, and medical concerns.Isr Med Assoc J2003;5,235-240. [PubMed]
 
Baker, MS Creating order from chaos: part I: triage, initial care, and tactical considerations in mass casualty and disaster response.Mil Med2007;172,233-236
 
Welling, L, Perez, RS, van Harten, SM, et al Analysis of the pre-incident education and subsequent performance of emergency medical responders to the Volendam cafe fire.Eur J Emerg Med2005;12,265-269. [PubMed]
 
Curiel, TJ Murder or mercy? Hurricane Katrina and the need for disaster training.N Engl J Med2006;355,2067-2069. [PubMed]
 
Brody, H, Cambell, ML, Faber, LK, et al Withdrawing intensive life-sustaining treatment-recommendations for compassionate clinical management.N Engl J Med1997;336,652-657. [PubMed]
 
Pantilat, SZ End-of-life care for the hospitalized patient.Med Clin N Am2002;86,749-770. [PubMed]
 
Von Gunten, C, Weissman, DE Ventilator withdrawal protocol.J Palliat Med2003;6,773-774. [PubMed]
 
Murphy P. Palliative management of common symptoms of discomfort. Available at: www.theuniversityhospital.com/healthlink/archives/palliative.html. Accessed April 4, 2008.
 
Rubenfeld, GD, Crawford, SW Principles and practice of withdrawing life-sustaining treatment in the ICU. Curtis, JF Rubenfeld, GD eds.Managing death in the intensive care unit.2001,127-147 Oxford University Press. Oxford, UK:
 
Krieger, BP Compassionate extubation: withdrawing mechanical ventilator support.Mediguide to Pulmonary Medicine2001;8,1-5
 
Moskop, JC, Iserson, KV Triage in medicine, part II: underlying values and principles.Ann Emerg Med2007;49,282-287. [PubMed]
 
Gostin, L, Bayer, R, Fairchild, A Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats.JAMA2003;290,3229-3237. [PubMed]
 
Heiling v Carey. A court’s view of the standard of care may differ from the medical profession’s view. Rule No 519P. 2d901 (Wash 1974).
 
Wessely, S The London attacks-aftermath: victimhood and resilience.N Engl J Med2005;353,548-550. [PubMed]
 
Center for Law and the Public’s Health. Model State Emergency Health Powers Act. Available at: http://www.publichealthlaw.net/. Accessed March 15, 2007.
 
Upshur, R, Singer, P Stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza: a report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group.2005,1-29 University of Toronto Joint Centre for Bioethics. Toronto, ON, Canada:
 
Vollmar, LC Military medicine in war: the Geneva conventions today. Beam, TE Sparacino, LR eds. Military medical ethics. 2003; Office of the Surgeon General, Department of the Army. Washington, DC:.
 
Task Force on Quality Control of Disaster Management.. Health disaster management: guidelines for evaluation and research in the Utstein style.Prehosp Disaster Med2003;17S,1-177
 

Figures

Figure Jump LinkFigure 1. Triage infrastructure: the optimal relationship between the state/regional central triage committee and the triage officer(s) at individual hospitals. The central triage committee must have situational awareness (knowledge of supply resources and demands on them), capacity to conduct research in order to develop then modify research protocols, and monitor triage outcomes. A bidirectional communication network between the central committee and hospitals in order to achieve situational awareness, monitor outcomes and communicate modifications to the triage protocols. At the individual hospitals, the triage officers(s) are supported by a staff/team.Grahic Jump Location
Figure Jump LinkFigure 2. Triage algorithm process: components 1 and 2, inclusion and exclusion criteria and prioritization of critical care resources.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Response Tiers for Critical Care Surge Capacity*
Table Graphic Jump Location
Table 1A. Continued
Table Graphic Jump Location
Table 1B. Continued
* 

From Rubinson et al, “Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity” in this Supplement. MACC = multiagency coordinating center.

Table Graphic Jump Location
Table 2. Potential Triggers To Initiate Triage Algorithm and Allocation of Resources at a Health-Care Facility Under EMCC
Table Graphic Jump Location
Table 3. Conditions Required To Initiate a Triage Process To Allocate Scarce Resources
Table Graphic Jump Location
Table 4. SOFA*
* 

How to calculate SOFA score: Each of the six components above is assigned a score based on a patient’s clinical or laboratory data; the total SOFA score is calculated by adding the score for each of the six components together. MAP = mean arterial pressure. Adapted from Moreno et al.18

Table Graphic Jump Location
Table 5. Comparison of Four Severity of Illness Scoring Systems
* 

From Vincent et al.17

 

Adapted from Knaus et al.13

 

From Lemeshow et al14 Higgins et al.15

§ 

From LeGall et al.16

Table Graphic Jump Location
Table 6. Exclusion Criteria
Table Graphic Jump Location
Table 7. Medical Record Documentation Suggestions
Table Graphic Jump Location
Table 8. Pediatric Triage Topics in Need of Further Study

References

Brannigan, M (2007) Deciding what is fair.Pract Bioethics2,1-2
 
Phillips, SJ, Knebel, A. Providing mass medical care with scarce resources: a community planning guide. 2006; Agency for Healthcare Research and Quality. Rockville, MD: publication 07–000.
 
Federal Emergency Management Agency.. National Incident Management System.2007,1-174 US Department of Homeland Security. Washington, DC:
 
Occupational Safety and Health Administration... Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. 2007; US Department of Labor. Washington, DC: publication 3328–05.
 
Burkle, FM Population-based triage management in response to surge-capacity requirements during a large-scale bioevent disaster.Acad Emerg Med2006;13,1118-1129. [PubMed] [CrossRef]
 
Centers for Disease Control and Prevention.. Tiered use of inactivated influenza vaccine in the event of a vaccine shortage.MMWR Morb Mortal Wkly Rep2005;54,749-450. [PubMed]
 
Powell, T, Christ, KC, Brikhead, GS Allocation of ventilators in a public health disaster.Dis Med Pub Health Prep2008;2,20-26
 
Hick, J, O'Laughlin, DT Concept of operations for triage of mechanical ventilation in an epidemic.Acad Emerg Med2006;13,223-229. [PubMed]
 
Christian, MD, Hawryluck, L, Wax, RS, et al Development of a triage protocol for critical care during an influenza pandemic.Can Med Assoc J2006;175,1377-1381
 
Task Force of the American College of Critical Care Medicine.. Guidelines for intensive care unit admission, discharge, and triage.Crit Care Med1999;27,633-638. [PubMed]
 
Sinuff, T, Kahnamoui, K, Cook, DJ, et al Rationing critical care beds: a systematic review.Crit Care Med2004;32,1588-1597. [PubMed]
 
Joynt, GM, Gomersall, CD, Tan, P, et al Prospective evaluation of patients refused admission to an intensive care unit: triage, futility, and outcome.Intensive Care Med2001;27,1459-1465. [PubMed]
 
Knaus, WA, Draper, EA, Wagner, DP, et al APACHE II: a severity of disease classification system.Crit Care Med1985;13,818-828. [PubMed]
 
Lemeshow, S, Teres, D, Klar, J, et al Mortality probability models (MPM II) based on an international cohort of intensive care unit patients.JAMA1993;270,2478-2486. [PubMed]
 
Higgins, TL, Teres, D, Copes, WS, et al Assessing contemporary intensive care unit outcome: an updated mortality probability admission model (MPM0-III).Crit Care Med2007;35,827-835. [PubMed]
 
LeGall, JR, Lemeshow, S, Saulnier, F A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study.JAMA1993;270,2957-2963. [PubMed]
 
Vincent, JL, Moreno, R, Takala, J, et al The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure.Intensive Care Med1996;22,707-710. [PubMed]
 
Moreno, R, Vincent, JL, Matos, R, et al The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care-results of a prospective, multicentre study.Intensive Care Med1999;25,686-696. [PubMed]
 
Ferreira, FL, Bota, DP, Bross, A, et al Serial evaluation of the SOFA score to predict outcome in critically ill patients.JAMA2001;286,1754-1758. [PubMed]
 
Vincent, J, Mendonca, A, Cantraine, F, et al Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study.Crit Care Med1998;26,1793-1800. [PubMed]
 
Cabre, L, Mancebo, J, Solsona, JF, et al Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of sequential organ failure assessment scores in decision making.Intensive Care Med2005;31,927-933. [PubMed]
 
Oda, S, Hirasawa, H, Sugai, T, et al Comparison of sepsis-related organ failure assessment (SOFA) score and CIS (cellular injury score) for scoring of severity for patients with multiple organ dysfunction syndrome (MODS).Intensive Care Med2000;26,1786-1793. [PubMed]
 
Peres-Bota, D, Melot, C, Lopes-Ferreira, F, et al The multiple organ dysfunction score (MODS) versus sequential organ failure assessment (SOFA) score in outcome prediction.Intensive Care Med2002;28,1619-1624. [PubMed]
 
Kajdacsy-Balla, AC, Andrade, FM, Moreno, R, et al Use of the sequential organ failure assessment (SOFA) scoring.Crit Care Med2005;31,243-249
 
Arts, DG, de Keizer, NF, Vroom, MB, et al Reliability and accuracy of sequential organ failure assessment (SOFA) scoring.Crit Care Med2005;33,1988-1993. [PubMed]
 
Vincent, JL Organ dysfunction in patients with severe sepsis.Surg Infect2006;7,S69-S72
 
Burkle, FM Mass casualty management of a large-scale bioterrorist event: an epidemiologic approach that shapes triage decisions.Emerg Med Clin N Am2002;20,409-436
 
Hick, JL, Rubinson, L, O'Laughlin, DT, et al Clinical review: allocating ventilators during large-scale disasters-problems, planning, and process.Crit Care2007;11,217-226. [PubMed]
 
Cone, DC, Koenig, KL Mass casualty triage in the chemical, biological, radiological, or nuclear environment.Eur J Emerg Med2005;12,287-302. [PubMed]
 
Truog, RD, Brock, DW, Cook, DJ, et al Rationing in the intensive care unit.Crit Care Med2006;34,958-964. [PubMed]
 
Garrouste-Oregas, M, Montuclard, L, Timsit, JF, et al Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes.Intensive Care Med2003;29,774-781. [PubMed]
 
Simchen, E, Sprung, CL, Galai, N, et al Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds.Crit Care Med2004;32,1654-1661. [PubMed]
 
Kluger, Y, Mayo, A, Soffer, D Functions and principles in the management of bombing mass casualty incidents: lessons learned at the Tel-Aviv Souraski medical center.Eur J Emerg Med2004;11,329-334. [PubMed]
 
Baker, MS Creating order out from chaos: part II. Tactical planning for mass casualty and disaster response at definitive care facilities.Mil Med2007;172,237-243. [PubMed]
 
Jaslow, D Disasters: experience and planning.Eur J Emerg Med2005;12,263-264. [PubMed]
 
Kennedy, K, Aghababian, RV, Gans, L, et al Triage: techniques and applications in decision making.Ann Emerg Med1996;28,136-144. [PubMed]
 
Rhyne, CD Wake-up call.Top Emerg Med2005;27,180-182
 
Beekley, AC, Starnes, BW, Sebesta, JA Lessons learned from modern military surgery.Surg Clin North Am2007;87,157-184. [PubMed]
 
Domres, B, Koch, M, Manger, A, et al Ethics and triage.Prehosp Disaster Med2001;16,53-58. [PubMed]
 
Hoey, B, Schwab, CW Level 1 center triage and mass casualties.Clin Ortho Relat Res2004;422,23-29
 
Kluger, Y Bomb explosions in acts of terrorism: detonation, wound ballistics, triage, and medical concerns.Isr Med Assoc J2003;5,235-240. [PubMed]
 
Baker, MS Creating order from chaos: part I: triage, initial care, and tactical considerations in mass casualty and disaster response.Mil Med2007;172,233-236
 
Welling, L, Perez, RS, van Harten, SM, et al Analysis of the pre-incident education and subsequent performance of emergency medical responders to the Volendam cafe fire.Eur J Emerg Med2005;12,265-269. [PubMed]
 
Curiel, TJ Murder or mercy? Hurricane Katrina and the need for disaster training.N Engl J Med2006;355,2067-2069. [PubMed]
 
Brody, H, Cambell, ML, Faber, LK, et al Withdrawing intensive life-sustaining treatment-recommendations for compassionate clinical management.N Engl J Med1997;336,652-657. [PubMed]
 
Pantilat, SZ End-of-life care for the hospitalized patient.Med Clin N Am2002;86,749-770. [PubMed]
 
Von Gunten, C, Weissman, DE Ventilator withdrawal protocol.J Palliat Med2003;6,773-774. [PubMed]
 
Murphy P. Palliative management of common symptoms of discomfort. Available at: www.theuniversityhospital.com/healthlink/archives/palliative.html. Accessed April 4, 2008.
 
Rubenfeld, GD, Crawford, SW Principles and practice of withdrawing life-sustaining treatment in the ICU. Curtis, JF Rubenfeld, GD eds.Managing death in the intensive care unit.2001,127-147 Oxford University Press. Oxford, UK:
 
Krieger, BP Compassionate extubation: withdrawing mechanical ventilator support.Mediguide to Pulmonary Medicine2001;8,1-5
 
Moskop, JC, Iserson, KV Triage in medicine, part II: underlying values and principles.Ann Emerg Med2007;49,282-287. [PubMed]
 
Gostin, L, Bayer, R, Fairchild, A Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats.JAMA2003;290,3229-3237. [PubMed]
 
Heiling v Carey. A court’s view of the standard of care may differ from the medical profession’s view. Rule No 519P. 2d901 (Wash 1974).
 
Wessely, S The London attacks-aftermath: victimhood and resilience.N Engl J Med2005;353,548-550. [PubMed]
 
Center for Law and the Public’s Health. Model State Emergency Health Powers Act. Available at: http://www.publichealthlaw.net/. Accessed March 15, 2007.
 
Upshur, R, Singer, P Stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza: a report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group.2005,1-29 University of Toronto Joint Centre for Bioethics. Toronto, ON, Canada:
 
Vollmar, LC Military medicine in war: the Geneva conventions today. Beam, TE Sparacino, LR eds. Military medical ethics. 2003; Office of the Surgeon General, Department of the Army. Washington, DC:.
 
Task Force on Quality Control of Disaster Management.. Health disaster management: guidelines for evaluation and research in the Utstein style.Prehosp Disaster Med2003;17S,1-177
 
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