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Care of the Critically Ill and Injured During Pandemics and DisastersGroundbreaking Results on Mass Critical Care: Groundbreaking Results from the Task Force on Mass Critical Care FREE TO VIEW

Christian E. Sandrock, MD, MPH, FCCP
Author and Funding Information

From the Intensive Care Unit, Division of Pulmonary and Critical Care, Division of Infectious Diseases, University of California, Davis School of Medicine.

CORRESPONDENCE TO: Christian E. Sandrock, MD, MPH, FCCP, Intensive Care Unit, Division of Pulmonary and Critical Care, Division of Infectious Diseases, University of California, Davis School of Medicine, 4150 V St #3400, Sacramento, CA 95817; e-mail: cesandrock@ucdavis.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential 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. See online for more details.


Chest. 2014;146(4):881-883. doi:10.1378/chest.14-1900
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Published online

The critically ill are a unique group of patients in a disaster response setting because they require resource-intensive care, advanced and costly therapies, and specialized settings and providers to deliver this care.1,2 They can present as a sudden surge of patients over a short period of time, pushing the limits of the health-care facility, or they can present over a sustained period of time, such as was the case of the 2009 influenza A(H1N1) pandemic, straining the larger regional health system. In many disasters, such as the London bombings, the critically ill can present as both an immediate surge and as a sustained intensive response, thus presenting varying response needs throughout the disaster.2,3 This variability with the most critically ill creates uncertainty in health-care response because local, regional, and national health-care systems may have resource limitations, a paucity of medical expertise, and structural compromise of health-care clinics and hospitals at any given moment. The current Ebola outbreak in West Africa best highlights the difficulties surrounding critically ill patients in a very resource-limited environment. However, regardless of the type of disaster and the extent of the critically ill, planning for this uncertainty in mass critical care is paramount to ensuring good patient outcomes.3-5

In 2008, the American College of Chest Physicians (CHEST) Task Force for Mass Critical Care published a series of suggestions with the aim of providing resource, logistic, and patient-flow planning for mass critical care in a disaster.1 Since the release of these documents, disasters and pandemics, most notably the 2009 influenza A(H1N1) pandemic the Haiti earthquake, and most recently the Ebola outbreak in West Africa, have provided additional learning experiences in mass critical care.3,5-7 Because the 2008 documents were limited in scope, without discussion of pediatrics, trauma, critical care in the developing world, and subspecialty critical care, the Task Force for Mass Critical Care was reconvened to provide a rigorously developed set of suggestions with an expanded scope and expertise to support critical care providers, hospital administrators, public health officials, and government planners. The result, published in CHEST, is an unparalleled, detailed series of 14 articles that lays the strongest foundation for disaster planning and response to date.8

The ultimate aim of the Task Force was to provide recommendations for the management of all adults and children critically ill because of a disaster or pandemic, regardless of where the care is provided. However, in the case of disaster response, no high-quality evidence exists from which to develop recommendations.9 Disaster response is rapid, large scale, and nonstandardized, and thus, the ability to develop real-time studies is extremely difficult. Evidence, therefore, is largely restricted to retrospective case series, provider experience, and expert opinion. To bridge this gap, the Task Force convened an unprecedented group of experts, from bedside physicians with deployment experience to medical societies to government representatives, to offer the best suggestions. Using a modified Delphi process, the Task Force approached all aspects of care, from the bedside to policy development to provider education, in both a resource-intensive and a resource-limited setting (the developing world).8 Although the Task Force’s 14 articles span many areas, their suggestions cover five main levels of disaster response and planning: patient care, disaster providers and responders, health-care systems and hospitals, local and regional governments, and community and society.

High-quality care of the critically ill is the foundation of all disaster response efforts.1,5,8,10 However, a disaster alters basic care delivery to the critically ill, and if preparedness is inadequate, this foundation can crumble, with adverse patient outcomes. The inability to respond to an increase in patients and resource demand has been directly linked to poor outcomes in a number of disasters.3,7,11,12 Therefore, the management of medications, medical supplies, oxygen therapy, mechanical ventilation, specialized services (eg, dialysis), and ICU location is detailed extensively over these 14 articles. Methods of conservation (particularly with scarce medication and oxygen therapy), substitution, and triage are a particular focus, with the goal of optimizing patient outcomes in mass critical care. These principles are very relevant today, where the resource limitations in West Africa are hindering both patient care and outbreak management. For example, minimal ventilator requirements are described to ensure both lung-protective strategies and that high positive end-expiratory pressure can be delivered in cases of ARDS. Antibiotic and antiviral substitutions for certain disease states are suggested, along with the minimal resources needed to manage a highly contagious disease among the critically ill. With this process, the Task Force suggestions create the strongest foundation of care delivery for the individual critically ill patient during a mass critical care.

With a strong foundation of patient care established, health-care providers for the critically ill need additional support to ensure adequate, high-quality care.11,12 As disasters evolve, treatments may change, thus requiring rapid education of providers.4 When resources are scarce, staff may need to triage those limited resources among many patients, therefore requiring an ethical system to determine resource use.1,2 An ICU subspecialist, such as a burn surgeon, may have a limited ability to cover large geographic areas. The Task Force suggestions place a particular emphasis on the use of technology and telemedicine, particularly surrounding an expanded scope of practice in some specialist-limited areas (eg, burns and trauma).8 Baseline education and just-in-time training, along with mental health support during difficult decision-making, is also designed to allow providers to deliver the best care without the impact larger resource decisions would have. With these suggestions, the health-care worker will be fully supported to deliver the best care possible at the bedside, with a structured framework for triage and clinical decision support, specialist support, and just-in-time education for difficult-to-treat illnesses.

To optimize provider support and patient outcomes in mass critical care, the Task Force offered a series of suggestions aimed at hospitals and health-care systems. The disaster literature focuses largely on patient-care delivery and provider support, and the Task Force realized that bedside care will suffer if health-care communities are not prepared.1,2,9 The transition from daily patient care, such as elective surgery, to disaster response and mass critical care is difficult, and if carried out poorly or late, can lead to poor patient outcomes.4,13 Most health systems require little storage with real-time delivery, and if not prepared with additional supplies, patient care can suffer with even smaller surges of critically ill patients.2,4,13 The disaster may involve the health system itself, and business operations may need relocation, thus affecting the continued ability to provide both structure and supplies.13 The Task Force recommendations of a 20% increase in surge within the health system resources to a 200% surge with regional and national resource support sets an international benchmark for health system preparedness. These suggestions, together with continuing operations planning and disaster team structure, provide the disaster response framework for a health system that can ensure optimal critical care delivery during a disaster.

In a disaster, the health-care system can deliver optimal critical care for a limited time, but eventually, regional and national governments must provide support. With mass critical care, the response system is stretched immediately, with resources, staffing, and patient flow impacted at the regional level.2,10,13 The suggestions of the Task Force, most notably the coordination of patient flow and resources, have not been described elsewhere in the literature or in other disaster planning documents. In a disaster, the traditional method of directly transferring a critically ill patient from a smaller, more remote hospital to a larger, tertiary center cannot occur independently of local and regional governments.1,2,4 If a tertiary center is impacted, public health and government officials must have the ability to triage patients and coordinate flow to a less impacted area.4,14 This process will require local and regional providers to understand the needs of mass critical care, including the ability to triage and recommend care substitutions, rather than to rely on local providers in the field to make these decisions.

In addition, the Task Force outlines these issues in more resource-limited settings, such as the developing world and areas without government support (nongovernmental organizations).8 Thus, during a spectrum of response by a government and health-care system, the progression of triage from conventional to conservation and contingency to crisis care has been fully aligned with this work.8 The Task Force’s vision of a large, central coordination of patient flow, resources, and critical care expertise sets a high but necessary benchmark for public health and government officials.

However, the most important aspect of the Task Force’s suggestions concerns the community and society. A large-scale disaster can leave both small and large populations without structure and government, and in the absence of a planned and timely response, health-care inequities can expand rapidly.1,14 These inequities can undermine any government or nongovernmental organization response, particularly within the populations most displaced and at risk, thus directly impacting patient outcomes.14 Perhaps the Task Force’s greatest contribution in these 14 manuscripts is when it discusses complex care delivery in an ethical and equal fashion to critically ill patients. Political careers have failed and governments have fallen when response to a disaster has been inadequate.14 If one resource is limited with adverse patient outcomes in one region while it is freely available in another region, patient care will be grossly inequitable. Despite excellent care delivery in these settings, population mistrust of health-care providers will occur and the high-quality response of front-line critical care providers will be greatly undermined.1,14 This mistrust will herald a larger collapse of the health system and eventually of the community. These principles are currently prevalent in West Africa, where the health-care community is seen as the source of the Ebola spread, and governments and health-care institutions are deemed inept, ineffectual, and a hindrance to good care. Thus, patients avoid the health-care system, further carrying and spreading disease. The effort of the Task Force to address inequity during disaster response, from resource allocation triage to care of special, vulnerable populations, is a massive step toward correcting these inequities at times of greatest stress on the health-care system.

While tackling the broad subject of mass critical care in a disaster, the Task Force perfectly balanced the individual with society, ultimately supporting the importance of justice. Any government official, politician, public health expert, or policy expert should incorporate these recommendations into disaster planning to ensure optimal patient outcomes in an equitable fashion. John Rawls,15 in A Theory of Justice, describes how individuals who make choices about society (eg, politicians) should consider resources concretely, because these resources, such as income, wealth, liberty, and opportunity, are ultimately the social basis for self-respect. Every person, regardless of circumstances, should have an equal right to the most extensive system of liberties. From an extreme paucity of evidence-based medicine, the Task Force has ultimately created a foundation of disaster response for the critically ill that provides justice to the most adversely affected patients. In the current literature, there is no guideline, recommendation, study, or consensus statement that can claim such a feat, and thus, the work of the Task Force is unparalleled.

References

Devereaux A, Christian MD, Dichter JR, Geiling JA, Rubinson L; Task Force for Mass Critical Care. Summary of suggestions from the Task Force for Mass Critical Care summit, January 26-27, 2007. Chest. 2008;133(5_suppl):1S-7S. [CrossRef] [PubMed]
 
Hick JL, Christian MD, Sprung CL; European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Chapter 2. Surge capacity and infrastructure considerations for mass critical care. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(suppl 1):S11-S20. [CrossRef] [PubMed]
 
Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219-2225. [CrossRef] [PubMed]
 
Gabriel LE, Webb SA. Preparing ICUs for pandemics. Curr Opin Crit Care. 2013;19(5):467-473. [CrossRef] [PubMed]
 
Westall GP, Paraskeva M. H1N1 influenza: critical care aspects. Semin Respir Crit Care Med. 2011;32(4):400-408. [CrossRef] [PubMed]
 
White DB, Angus DC. Preparing for the sickest patients with 2009 influenza A(H1N1). JAMA. 2009;302(17):1905-1906. [CrossRef] [PubMed]
 
Dulski TM, Basavaraju SV, Hotz GA, et al. Factors associated with inpatient mortality in a field hospital following the Haiti earthquake, January-May 2010. Am J Disaster Med. 2011;6(5):275-284. [CrossRef] [PubMed]
 
Christian MD, Devereaux AV, Dichter JR, Rubinson L, Kissoon N; on behalf of the Task Force for Mass Critical Care. Introduction and executive summary: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):8S-34S.
 
Memoli MJ. Pandemic research in the ICU: always be prepared. Crit Care Med. 2013;41(4):1147-1148. [CrossRef] [PubMed]
 
Altevogt BM, Stroud C, Hanson SL, Hanfling D, Gostin LO., eds; Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations; Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: National Academy Press; 2009. [PubMed] [PubMed]
 
Moszynski P. Death toll climbs and healthcare needs escalate in Japan. BMJ. 2011;342:d1859. [CrossRef] [PubMed]
 
Raiter Y, Farfel A, Lehavi O, et al. Mass casualty incident management, triage, injury distribution of casualties and rate of arrival of casualties at the hospitals: lessons from a suicide bomber attack in downtown Tel Aviv. Emerg Med J. 2008;25(4):225-229. [CrossRef] [PubMed]
 
Powell T, Hanfling D, Gostin LO. Emergency preparedness and public health: the lessons of Hurricane Sandy. JAMA. 2012;308(24):2569-2570. [CrossRef] [PubMed]
 
Zack N. Philosophy and disaster. Homeland Security Affairs. 2006;2(1):1-13.
 
Rawls J. A Theory of Justice.Rev. ed. Boston, MA: Belknap Press of Harvard University Press; 1999.
 

Figures

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References

Devereaux A, Christian MD, Dichter JR, Geiling JA, Rubinson L; Task Force for Mass Critical Care. Summary of suggestions from the Task Force for Mass Critical Care summit, January 26-27, 2007. Chest. 2008;133(5_suppl):1S-7S. [CrossRef] [PubMed]
 
Hick JL, Christian MD, Sprung CL; European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Chapter 2. Surge capacity and infrastructure considerations for mass critical care. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(suppl 1):S11-S20. [CrossRef] [PubMed]
 
Aylwin CJ, König TC, Brennan NW, et al. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet. 2006;368(9554):2219-2225. [CrossRef] [PubMed]
 
Gabriel LE, Webb SA. Preparing ICUs for pandemics. Curr Opin Crit Care. 2013;19(5):467-473. [CrossRef] [PubMed]
 
Westall GP, Paraskeva M. H1N1 influenza: critical care aspects. Semin Respir Crit Care Med. 2011;32(4):400-408. [CrossRef] [PubMed]
 
White DB, Angus DC. Preparing for the sickest patients with 2009 influenza A(H1N1). JAMA. 2009;302(17):1905-1906. [CrossRef] [PubMed]
 
Dulski TM, Basavaraju SV, Hotz GA, et al. Factors associated with inpatient mortality in a field hospital following the Haiti earthquake, January-May 2010. Am J Disaster Med. 2011;6(5):275-284. [CrossRef] [PubMed]
 
Christian MD, Devereaux AV, Dichter JR, Rubinson L, Kissoon N; on behalf of the Task Force for Mass Critical Care. Introduction and executive summary: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):8S-34S.
 
Memoli MJ. Pandemic research in the ICU: always be prepared. Crit Care Med. 2013;41(4):1147-1148. [CrossRef] [PubMed]
 
Altevogt BM, Stroud C, Hanson SL, Hanfling D, Gostin LO., eds; Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations; Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: National Academy Press; 2009. [PubMed] [PubMed]
 
Moszynski P. Death toll climbs and healthcare needs escalate in Japan. BMJ. 2011;342:d1859. [CrossRef] [PubMed]
 
Raiter Y, Farfel A, Lehavi O, et al. Mass casualty incident management, triage, injury distribution of casualties and rate of arrival of casualties at the hospitals: lessons from a suicide bomber attack in downtown Tel Aviv. Emerg Med J. 2008;25(4):225-229. [CrossRef] [PubMed]
 
Powell T, Hanfling D, Gostin LO. Emergency preparedness and public health: the lessons of Hurricane Sandy. JAMA. 2012;308(24):2569-2570. [CrossRef] [PubMed]
 
Zack N. Philosophy and disaster. Homeland Security Affairs. 2006;2(1):1-13.
 
Rawls J. A Theory of Justice.Rev. ed. Boston, MA: Belknap Press of Harvard University Press; 1999.
 
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