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Lewis Rubinson, MD, PhD, FCCP; Dennis Amundson, DO, FCCP; Michael David Christian, MD; James Geiling, MD, FCCP; Asha Devereaux, MD, MPH, FCCP
Author and Funding Information

Affiliations: University of Washington Seattle, WA,  Naval Medical Center San Diego, CA,  Mount Sinai Hospital Toronto, ON, Canada,  White River Junction Veterans Affairs Medical Center Hanover, NH,  Sharp Coronado Hospital Coronado, CA

Correspondence to: Asha Devereaux, MD, MPH, FCCP, Pulmonary/Critical Care, 1224 10th St, No. 205, Coronado, CA 92118; e-mail: adevereaux@pol.net


The opinions expressed do not reflect the official positions of the Department of Veterans Affairs or the Department of Defense.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(4):1108-1109. doi:10.1378/chest.08-2957
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To the Editor:

We appreciate and agree with the triage concepts put forth by Subbarao and his distinguished coauthors.1 Prior to the framework proposed by the Task Force for Mass Critical Care, regional coordination of individual ICUs in the United States had undergone limited conceptual development. Much detailed guidance was needed for critical care professionals to enhance surge capability and optimally allocate scarce life-saving interventions during disasters. This was the focus of the framework of the task force, but, for clarification, we agree that critical care triage should not happen in isolation. Instead, the framework was intended to be integrated into a broader triage system.26

Given the experience with severe acute respiratory syndrome (or SARS) a few years ago and the burgeoning concern about a serious influenza pandemic, we focused primarily on disasters causing numerous medically critically ill victims. The composition of our group was deliberately conceived to bring medicine, ethics, and public health experts together to collaboratively develop pragmatic, optimal clinical guidance. We knew that future work on critical care surge capability and triage for pediatric and trauma issues would be necessary, and work by Subbarao and colleagues7 has advanced additional, essential elements of triage planning.

The challenges of optimal triage across the entire health-care system spectrum are many. Even the goals of triage, such as mortality vs life-years saved or other outcomes, have not received sufficient professional consideration or input from community members. Furthermore, health system situational awareness (ie, patient needs and resource availability) needs much more real-time and detailed clinical information to optimally inform centralized triage recommendations. The capability to rapidly understand the course of a disease, identify prognostic variables, and determine treatment effectiveness across the entire health-care system remains elusive for most communities. This information will be essential for sustained-response events such as epidemics, when data-driven revisions of triage guidance would be expected to ensure that our community members get the best possible care in resource-limited circumstances. Finally, regional coordination of health-care system triage will require input from many different clinical specialties and professions as well as from nonclinical community members, such as elected officials, community advocates, and at-large community members, among whom are many of the same people who must provide consultation during responses. The majority of communities must still further develop their regional health-care system coordination infrastructure to assure such clinical expert involvement.

Subbarao I, Bostick NA, Burkle FM, et al. Re-envisioning mass critical care triage as a systemic multitiered process [letter]. Chest. 2009;135:1108. [PubMed] [CrossRef]
 
Devereaux A, Dichter JR, Christian MD, et al. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Chest. 2008;133(suppl):51S-66S
 
Christian M, Devereaux A, Dichter J, et al. Definitive care for the critically ill during a disaster: current capabilities and limitations. Chest. 2008;133suppl:8S-17S. [PubMed]
 
Rubinson L, Hick J, Hanfling D, et al. Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity. Chest. 2008;133suppl:18S-31S. [PubMed]
 
Rubinson L, Hick J, Curtis JR, et al. Definitive care for the critically ill during a disaster: medical resources for surge capacity. Chest. 2008;133suppl:32S-51S. [PubMed]
 
Devereaux A, Christian M, Dichter J, et al. Summary of suggestions from the task force for mass critical care summit. Chest. 2008;133suppl:1S-7S. [PubMed]
 
Bostick N, Subbarao D, Burkle FM, et al. Disaster triage systems for large-scale catastrophic events. Disaster Med Public Health Prep. 2008;133suppl:S35-S39
 

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References

Subbarao I, Bostick NA, Burkle FM, et al. Re-envisioning mass critical care triage as a systemic multitiered process [letter]. Chest. 2009;135:1108. [PubMed] [CrossRef]
 
Devereaux A, Dichter JR, Christian MD, et al. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Chest. 2008;133(suppl):51S-66S
 
Christian M, Devereaux A, Dichter J, et al. Definitive care for the critically ill during a disaster: current capabilities and limitations. Chest. 2008;133suppl:8S-17S. [PubMed]
 
Rubinson L, Hick J, Hanfling D, et al. Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity. Chest. 2008;133suppl:18S-31S. [PubMed]
 
Rubinson L, Hick J, Curtis JR, et al. Definitive care for the critically ill during a disaster: medical resources for surge capacity. Chest. 2008;133suppl:32S-51S. [PubMed]
 
Devereaux A, Christian M, Dichter J, et al. Summary of suggestions from the task force for mass critical care summit. Chest. 2008;133suppl:1S-7S. [PubMed]
 
Bostick N, Subbarao D, Burkle FM, et al. Disaster triage systems for large-scale catastrophic events. Disaster Med Public Health Prep. 2008;133suppl:S35-S39
 
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