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Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement Online Only Articles |

Surge Capacity LogisticsSurge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement FREE TO VIEW

Sharon Einav, MD; John L. Hick, MD; Dan Hanfling, MD; Brian L. Erstad, PharmD; Eric S. Toner, MD; Richard D. Branson, MSc, RRT; Robert K. Kanter, MD; Niranjan Kissoon, MBBS, FRCPC; Jeffrey R. Dichter, MD; Asha V. Devereaux, MD, MPH, FCCP; Michael D. Christian, MD, FRCPC, FCCP; on behalf of the Task Force for Mass Critical Care
Author and Funding Information

From the Shaare Zedek Medical Center (Dr Einav), Hebrew University Faculty of Medicine, Jerusalem, Israel; Hennepin County Medical Center (Dr Hick), University of Minnesota, Minneapolis, MN; Inova Health System (Dr Hanfling), Falls Church, VA; George Washington University (Dr Hanfling), Washington, DC; University of Arizona (Dr Erstad), Tucson, AZ; UPMC Center for Health Security (Dr Toner), University of Pittsburgh Medical Center, Baltimore, MD; University of Cincinnati (Dr Branson), Cincinnati, OH; SUNY Upstate Medical University (Dr Kanter), Syracuse, NY; Columbia University (Dr Kanter), New York, NY; BC Children’s Hospital and Sunny Hill Health Centre (Dr Kissoon), University of British Columbia, Vancouver, BC, Canada; Allina Health (Dr Dichter), Minneapolis, MN; Aurora Healthcare (Dr Dichter), Milwaukee, WI; Sharp Hospital (Dr Devereaux), Coronado, CA; Royal Canadian Medical Service (Dr Christian), Canadian Armed Forces and Mount Sinai Hospital, Toronto, ON, Canada.

CORRESPONDENCE TO: Sharon Einav, MD, Surgical Intensive Care, Shaare Zedek Medical Center, POB 3235, Jerusalem 91031, Israel; e-mail: einav_s@szmc.org.il


FUNDING/SUPPORT: This publication was supported by the Cooperative Agreement Number 1U90TP00591-01 from the Centers of Disease Control and Prevention, and through a research sub award agreement through the Department of Health and Human Services [Grant 1 - HFPEP070013-01-00] from the Office of Preparedness of Emergency Operations. In addition, this publication was supported by a grant from the University of California–Davis.

COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

DISCLAIMER: American College of Chest Physicians guidelines and consensus statements are intended for general information only, are not medical advice, and do not replace professional care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this consensus statement can be accessed at http://dx.doi.org/10.1378/chest.1464S1.

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_suppl):e17S-e43S. doi:10.1378/chest.14-0734
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BACKGROUND:  Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics—those elements that provide the capability to deliver mass critical care.

METHODS:  The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee’s methodology to develop suggestion based on expert opinion using a modified Delphi process.

RESULTS:  This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response.

CONCLUSIONS:  Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

Figures in this Article
Stockpiling of Equipment, Supplies, and Pharmaceuticals

1. We suggest hospital support services, including pharmacy, laboratory, radiology, respiratory therapy, and nutrition services, also be included in the planning of critical care surge.

2. We suggest equipment, supplies, and pharmaceutical stockpiles specific to the delivery of mass critical care (MCC) be interoperable and compatible at the regional level and ideally at the state/provincial level, so as to ensure uniformity of response capabilities, coordinated training, and a mechanism for exchange of material among facilities.

3. We suggest facilities should ensure adequate availability of disaster supplies through facility-based caches, with vendor agreements and understanding of supply chain resources and limitations.

4. We suggest the existing MCC hospital target lists for basic equipment, supplies, and pharmaceuticals remain relevant for institutions seeking to plan for MCC response.

5. We suggest regional and hospital stockpiles include equipment, supplies, and pharmaceuticals that can be used to accommodate the needs of unique populations that are likely to require critical care in centers other than specialty care centers, including pediatric, burn, and trauma patients.

Staff Preparation and Organization

6. We suggest hospitals use adaptive measures to compensate for reduced staffing, such as additional shifts, workload, and changes in shift structure/time, should be planned in collaboration with the critical care staff representatives.

7. We suggest hospital staff preparation for response to a disaster is vitally important to the successful outcomes of such events and should include emphasis on role definition, integration with the incident command system, and the ability to perform cross-trained functions.

8. We suggest hospital staff preparedness to support critical care surge response include knowledge of the following: standard operating procedures, role definition, use of hospital incident command system, cross-training of additional staff, and training in the use of situational awareness tools, particularly those that can assist in decision-making regarding critical care surge planning, operations, response, and recovery.

9. We suggest once a disaster or pandemic has occurred, hospitals should implement measures to mitigate preventable causes of staff shortage, including sheltering of staff and their families, provision of mental health support, measures to mitigate fatigue, access to transportation services, and maintenance of a safe working environment.

10. We suggest critical care nurse-to-patient ratios in an event requiring critical care surge be determined by provider experience, available support (ancillary staff), and clinical demands.

11. During a disaster or pandemic, we suggest critical care physician oversight and direction of the clinical care teams who provide critical care services, including scheduled patient assessment and treatment plan evaluation. If direct oversight is unavailable, a means of remote consultation should be used.

12. Should expert consultation (eg, pediatrics, trauma, burn, or critical care) not be available locally, we suggest every effort be made by hospitals to ensure that such expertise be provided at a minimum through remote consultation.

13. We suggest hospitals consider the utilization of technology (eg, telemedicine) as an important adjunct to the delivery of critical care services in a disaster to serve as a force multiplier to support response to disaster events. Where no such systems are currently in place, development of a telemedicine or other electronic platform to support patient care delivery is suggested.

Patient Flow and Distribution

14. We suggest decisions regarding in-hospital placement of critically ill patients during an MCC (after initial survey and treatment) be performed by an experienced clinician who makes similar triage decisions on a daily basis.

15. Early discharge of ICU patients to the general ward is a complex process, requiring critical care expertise. To enable rapid admission of critically ill patients to the ICU immediately after termination of ED/operating room workup and treatment, we suggest discharge of ICU patients (when possible) during preparation for an impending MCC be given priority simultaneous to decisions made about initial ED patient distribution.

Deployable Critical Care Services

16. We suggest deployable critical care services be considered a temporary alternative to critical care when loss of hospital infrastructure limits provision of critical care.

17. We suggest deployable critical care services are not definitive critical care facilities but may be used as a temporizing measure for delivery of critical care in a disaster setting. Expansion of critical care resources in the hospital environment, with temporary facilities for lesser acuity patients, is preferred over provision of deployable critical care when possible.

18. We suggest deployable critical care services may serve as temporary critical care locations provided there is a clear plan for patient transfer, within a few hours to days, to a definitive treatment location.

19. In crisis surge response, we suggest less intensive treatment of moderately injured patients be prioritized over the deployment of temporary critical care services when it would result in improved outcomes for larger numbers of patients.

Using Transportation Assets to Support Surge Response

20. We suggest surge capacity plans include predetermined standards that define minimal ongoing critical care capability in order to define the framework for decisions regarding patient transfer as the demands on the system gradually increase during a disaster or pandemic.

21. We suggest priority be given to transfer of assets to patients, particularly when transfer of patients to definitive care is limited by dangerous conditions (including considerable risk posed by available transportation options).

22. Transportation used for patient evacuations may also be used to bring in assets (eg, specialty providers and equipment), particularly when access/transport capacity is the limiting factor in patient movement.

Successful management of a disaster or pandemic requires implementation of preexisting plans to minimize loss of life and prevent event expansion and secondary illness and injury. These plans are strategic documents and policies that should be developed in preparation for a surge during a disaster or pandemic and should be accompanied by rigorous training to ensure best outcomes. Many facilities do not incorporate critical care in their disaster plans or have critical care expansion plans that are separate from their all-hazard response plan. However, critical care is an important component of the hospital response to a disaster,1-3 and managing surges in the ICU cannot be accomplished in isolation. A systems perspective, which includes all the organizations and persons involved as well as intensive care, is necessary. Planning should take into account the 12 disaster scenarios most likely to involve large numbers of critically ill or injured patients as outlined by the US Department of Homeland Security National Preparedness Guidelines.4 Critical care surge capacity is defined as the maximal number of critical casualties that can receive adequate critical care for as long as required, regardless of patient placement, after recruiting all critical care assets. In a companion article in this guideline, we examine issues related to surge operations, describing the conduct of mass critical care (MCC).5 The suggestions in this article are important for all who are involved in a disaster or pandemic with multiple critically ill patients, including frontline clinicians, hospital administrators, and public health or government officials. Although it is important for all providers to be familiar with all aspects of surge capacity logistics, Table 1 provides an overview of the suggestions of most interest to various stakeholders. In this article, we specifically focus on surge logistics: the elements that provide the capability to deliver MCC in disaster events (Table 2).

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TABLE 1 ]  Primary Target Audiences for Suggestions
Table Graphic Jump Location
TABLE 2 ]  An Overview of the Critical Care Surge Planning Process

(Adapted from Christian et al6 and the Ontario Ministry of Health and Long-Term Care.7)

The Surge Capacity topic group met in June 2012 and developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Four literature searches were conducted to identify studies upon which evidence-based recommendations could be made. Searches were limited to between January 1995 and October 2012; English-language articles were included and non-English-language articles excluded (e-Appendix 1). A total of 1,440 articles were identified. The articles were reviewed for relevance to the topic by two topic editors (S. E. and J. L. H.). The lead topic editor (D. H.) was responsible for “deconflicting” the results where initial consensus was not achieved. Seven hundred twenty-seven articles were deemed relevant to the subject of surge capacity planning and response. Most reports were small scale, were observational, or used flawed or limited modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee’s methodology to develop suggestions based on expert opinion through a modified Delphi process.8e-Appendix 1 contains key questions, key suggestions, and corresponding search terms and results.

Stockpiling of Equipment, Supplies, and Pharmaceuticals

1. We suggest hospital support services, including pharmacy, laboratory, radiology, respiratory therapy, and nutrition services, also be included in the planning of critical care surge.

2. We suggest equipment, supplies, and pharmaceutical stockpiles specific to the delivery of MCC be interoperable and compatible at the regional level, and ideally at the state/provincial level, so as to ensure uniformity of response capabilities, coordinated training, and a mechanism for exchange of material among facilities.

3. We suggest facilities should ensure adequate availability of disaster supplies through facility-based caches, with vendor agreements and understanding of supply chain resources and limitations.

4. We suggest the existing MCC hospital target lists for basic equipment, supplies, and pharmaceuticals remain relevant for institutions seeking to plan for MCC response.

5. We suggest regional and hospital stockpiles include equipment, supplies, and pharmaceuticals that can be used to accommodate the needs of unique populations that are likely to require critical care in centers other than specialty care centers, including pediatric, burn, and trauma patients.

Policies should enable programs to optimize critical care resources available to a hospital. The existing framework for optimizing resources includes substitution, conservation, use of less-resource-intensive therapies, and, in the worst-case scenario, reuse or reallocation of scarce resources.5 Stockpiling of equipment, supplies, and pharmaceuticals prior to a disaster or pandemic increases hospital surge capacity. A current focus on just-in-time inventory management limits stockpiling and requires constant vigilance and advocacy to ensure that key supplies are available. Thus, the development and oversight of equipment, supplies, and pharmaceutical stockpiles to deliver MCC is an integral function of local, regional, state or province, or national health-care emergency management programs. The ability to deliver effective critical care hinges on the maintenance of adequate supplies of narcotics, sedatives, antibiotics, vascular access supplies, and laboratory reagents that often are targeted for reduced stocking. Regional discussions of stockpiling based on the hazards faced by the community are central to the planning process. A coordinated approach to planning, purchasing, and stockpiling can lead to a much more robust and effective response than any single-facility efforts. Mechanisms for coordination of supply and staff during an event are detailed in the “Surge Capacity Principles” article by Hick et al5 in this consensus statement. Regional stockpiles of critical medical supplies (particularly those used routinely and those that are likely to be required before outside supplies can arrive) at multiple medical facilities can be used to enhance critical care surge preparedness.9

Critical care surge capabilities rely on support from pharmacy, laboratory, radiology, respiratory therapy, and nutrition services; hence, these should be included in all plans. Critical care experts should discuss with their pharmacy and central supply the quantities that should be readily available and determine arrangements should these supplies become exhausted.10 Up to one-fifth of the patients admitted to hospitals after a major disaster may present with respiratory complications11,12; thus, respiratory care should also be involved in the institutional plans for operating a significantly greater number of ventilators than usual. Similarly, pharmacy and radiology usual practices may be altered during disasters, and laboratories may need to limit routine services to focus on critical testing.13-16

Health-care facilities should also have local plans to institute substitution, conservation, adaptation, reuse, and reallocation of scarce resources.17,18 For drugs, these plans may require input from pharmacists and specialist clinicians. For example, infectious disease specialists may need to work in concert with pharmacists when antibiotic substitution or conservation strategies are contemplated.19-22

Successful implementation of conservation strategies relies on education and training as well as on preparation. For example, conservation of oxygen depends on implementation of standard operating procedures regarding the indications for supplemental oxygen and training to target oxygen saturation to > 89% rather than to > 95% as well as on the choice of liquid oxygen and compression-driven ventilators.23 Inconsistent or even conflicting approaches can be avoided if national societies or bodies, such as the US Food and Drug Administration, provide basic templates and guidance so that individual institutions are not required to conduct these efforts independently.

Individual hospitals can optimize the use of stockpiled equipment, supplies, and pharmaceuticals if systems for pre-event preparation, cache monitoring, updating, and oversight and coordination policies during an event are used.18 In general, the existing target lists of ancillary equipment for surge positive pressure ventilation (Table 3), medical equipment for critical care surge (Table 4), and pharmaceuticals (Table 5) remain relevant for institutions seeking to plan for pandemic and disaster response.17,18,25 Similar target lists for pediatric critical care surge can be found in a dedicated article by the Task Force for Pediatric Emergency Mass Critical Care.24

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TABLE 3 ]  Suggested Ancillary Equipment for Surge Positive Pressure Ventilation

Pediatric-specific equipment, although not presented in order to limit the complexity of the suggestions, should be considered. Some devices may be used interchangeably for adults and most pediatric patients (eg, mechanical ventilators approved for adult and pediatric use). Amounts of pediatric-specific equipment should be determined by regional analysis of need in consultation with pediatric experts.24etco2 = end tidal CO2; HEPA = high-efficiency particulate air; HME = heat and moisture exchanger; MDI = metered-dose inhaler; psi = pounds per square inch. (Adapted with permission from Rubinson et al.15)

a 

Consumable equipment for 10 patient care spaces for 10 d assumes 30% patient turnover due to clinical improvement and death.

b 

Does not include endotracheal intubation/tracheostomy equipment. Pharmaceuticals and intubation equipment should be available.

c 

Numbers will depend on decision to use a circuit with or without a heated wire. If HMEs are stockpiled exclusively, then existing heated humidifiers can still be assigned for patients with copious secretions or high minute ventilation.

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TABLE 4 ]  Suggested Medical Equipment for Critical Care Surge

CVC = central venous catheter; N/A = not applicable; NIBP = noninvasive (automatic) BP; PICC = percutaneous inserted central catheter. (Adapted with permission from Rubinson et al.15)

a 

Equipment for 10 patient care spaces for 10 d assumes 30% patient turnover (clinical improvement and deaths).

b 

Pediatric-specific equipment, although not presented to limit the complexity of the suggestions, should be considered.24 Some devices may be used interchangeably for adults and most pediatrics (eg, mechanical ventilators approved for adult and pediatric use). Amounts of pediatric-specific equipment should be determined by regional analysis of need in consultation with pediatric experts.

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TABLE 5 ]  Suggested Pharmaceuticals

GCSF = granulocyte colony-stimulating factor. (Adapted with permission from Sprung and Kesecioglu.18)

Mechanical Ventilation Surge:

Ventilatory support is an absolute necessity for survival in critically ill patients and may be the single most important therapy that dictates outcome. Moreover, ventilators are expensive and likely to be the limiting factor in any hospital’s ability to accommodate a large MCC surge. Currently, US hospitals own approximately 65,000 full-feature ventilators and 100,000 less-advanced ventilators26 to serve 93,955 ICU beds.27 Hospitals working individually are unlikely to have enough ventilators stockpiled to double their ventilatory capacity in accordance with crisis surge requirements. Vendors will also be unable to supply a large number of ventilators on short notice. We suggest that health-care coalition surge objectives be consistent with individual hospital surge goals5 and include the capability to surge at least up to the limit of the total number of ventilators available to coalition partners.28

A practical solution to this shortfall is to undertake a regional count of ventilators and a map of ventilation capacity per zone. A region’s MCC operational plan would be built around that map, which outlines shortfalls and target goals for the regional ventilator stockpile. With clear targets, hospitals and coalitions will likely be motivated to stockpile ventilators to meet these goals. Thus, facilities should first assess their capacity to use anesthesia machines, noninvasive ventilation machines, and transport ventilators for potential redeployment. Although simple pressure-triggered ventilators may play some role when lung compliance is normal, in most disasters and pandemics, they will be of very limited utility.29 Stockpiled mechanical ventilators must meet unique needs, which should be considered before selection (Table 6).

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TABLE 6 ]  Operating, Performance, Safety, and Maintenance Features to Be Sought in Stockpiled Mechanical Ventilators

AC = alternating current; ASTM = American Society for Testing and Materials; DC = direct current; EMC = electromagnetic compatibility; FDA = US Food and Drug Administration; I:E = inspiratory:expiratory; ISO = International Standards Organization; PEEP = positive end-expiratory pressure; RH = relative humidity; SIMV = synchronized intermittent mechanical ventilation; Vt = tidal volume; USD = US dollars. See Table 3 legend for expansion of other abbreviation. (Adapted with permission from Rubinson et al.15)

Facilities should also map their ability to provide mechanical ventilatory support. The first question is which hospital areas are capable of supporting mechanical ventilation: The availability of physical space, air and oxygen supply, expired gas clearance, and negative pressure for suction should all be examined. The second question is whether the hospital infrastructure is capable of supporting the planned surge. The existing infrastructure should be studied not only in terms of the power requirements and oxygen supply but also in light of the most likely regional hazards. For example, during Hurricane Katrina, hospitals suffered generator power outages30 and had to move ancillary departments (eg, biomedical engineering, central supplies) because their location had exposed them to flooding.31 During the Lebanon war, a hospital within the missile striking zone had to convert ED areas into operating rooms because the latter were not designed to withstand artillery and missile attack.32

Mechanical ventilation of a patient places implicit constraints on the system; it is highly demanding in terms of staff (both time and training), equipment, and consumable supplies. Depending on the type of disaster or pandemic, the surge of mechanical ventilation is expected to last at least several weeks.33-36 Initiation of mechanical ventilation during a pandemic or disaster is a weighty decision. Once initiated, withdrawal of ventilation, although ethically defensible, may be legally challenging,37,38 depending on the jurisdiction. Those making decisions to intubate patients during an MCC event should be aware of the immediate and long-term implications of their decisions39 and seek alternative options where possible.40 Decisions regarding manual ventilation should be made per event and should take into account the time and physical costs of manual ventilation, the inherent risk of close contact with the patient for the staff, ventilator and staff availability and training, and the time manual ventilation is likely to be required.

Staff Preparation and Organization

6. We suggest hospitals use adaptive measures to compensate for reduced staffing, such as additional shifts, workload, and changes in shift structure/time, should be planned in collaboration with the critical care staff representatives.

Delivery of critical care depends on the availability of sufficiently trained medical, nursing, and ancillary staff. Because acute care hospitals operate around the clock, the available personnel may be doubled or even tripled rapidly through recruitment of off-shift staff. This arrangement generally suffices for treatment of the initial wave of patients. However, a continued response is likely to consume the available reserves of rested personnel within 24 to 48 h. Because the critical care needs in a disaster or pandemic are more prolonged than the response in other sections of the hospital,4,5,41-44 the likelihood of depleting staff reserves is greater in the ICU. Planning ahead for phased staff callbacks (eg, staged callbacks when a disaster is declared so that all staff do not respond at once) and automatic consideration of staffing needs for 12, 24, and 48 h postevent to determine need and coverage and make appropriate plans (eg, notifying patients of clinic closures and rescheduling to allow staff to provide inpatient care) can greatly facilitate safe and effective coverage for the duration of the surge.

Preparation:

7. We suggest hospital staff preparation for response to a disaster is vitally important to the successful outcomes of such events and should include emphasis on role definition, integration with the incident command system, and the ability to perform cross-trained functions.

8. We suggest hospital staff preparedness to support critical care surge response include knowledge of the following: standard operating procedures, role definition, use of hospital incident command system, cross-training of additional staff, and training in the use of situational awareness tools, particularly those that can assist in decision-making regarding critical care surge planning, operations, response, and recovery.

9. We suggest once a disaster or pandemic has occurred, hospitals should implement measures to mitigate preventable causes of staff shortage, including sheltering of staff and their families, provision of mental health support, measures to mitigate fatigue, access to transportation services, and maintenance of a safe working environment.

Adaptive measures to compensate for reduced staffing, such as additional shifts, workload, transition-to-care teams, and changes in shift structure, should be planned in collaboration with the critical care staff (Table 7). Routine services that affect the ability to effectively respond to the pandemic or disaster (eg, elective surgery, clinic services) can be curtailed in order to reassign staff to pandemic- or disaster-relevant duties.32 New divisions of labor may be required and should be based on the skill sets required rather than traditional roles or functions of providers. The use of care teams, that is, combinations of providers who cumulatively possess the required skill set, should be considered.17,25,45 Additionally, administrative and teaching responsibilities should be curtailed during surge operations (including cancellation of meetings not related to the incident), policies should be in place about rescinding vacations and leave, and documentation requirements should be altered to free up time for direct patient care.

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TABLE 7 ]  Methods of Augmenting Critical Care Manpower Surge

MCC = mass critical care.

Nursing Staff:

10. We suggest critical care nurse-to-patient ratios in an event requiring critical care surge be determined by provider experience, available support (ancillary staff), and clinical demands.

Increased nurse-to-patient ratios provides improved safety and better outcomes for patients.46 Although controversial, high nurse-to-patient ratios have been associated with a lower risk for ventilator-associated pneumonia47 and lower mortality rates in neonatal ICUs.48 Patient care is increasingly compromised at higher ratios of patients to staff, with data suggesting a 7% increase in adverse outcomes for each patient above 4:1 in general medical surgical care.49

However, when providing care during a disaster or pandemic, it is not feasible to maintain the typical 1:1 or 1:2 North American ICU nurse-to-patient ratios. Hence, strategies such as the use of care teams with noncritical care trained nurses off-loading tasks within their skill set from the critical care nurses should be used to mitigate the potential for harm. A similar model has been proposed by project XTREME (Cross-Training Respiratory Extenders for Medical Emergencies) where respiratory extenders are employed during emergencies to compensate for high patient-to-respiratory therapist ratios.50 Although the benefits and limits of skilled task off-loading and nurse-to-patient ratios in disasters are unclear, there will be a tipping point beyond which higher ratios will lead to such poor outcomes that delivery of critical care confers no benefit. This supposition has led hospitals planning for radiation-related casualties to plan a nurse-to-patient ratio not to exceed 8:1.51

Physician Staff:

11. During a disaster or pandemic, we suggest critical care physician oversight and direction of the clinical care teams who provide critical care services, including scheduled patient assessment and treatment plan evaluation. If direct oversight is unavailable, a means of remote consultation should be used.

12. Should expert consultation (eg, pediatrics, trauma, burn, or critical care) not be available locally, we suggest every effort be made by hospitals to ensure that such expertise be provided at a minimum through remote consultation.

13. We suggest hospitals consider the utilization of technology (eg, telemedicine) as an important adjunct to the delivery of critical care services in a disaster to serve as a force multiplier to support response to disaster events. Where no such systems are currently in place, development of a telemedicine or other electronic platform to support patient care delivery is suggested.

Daily patient management by a critical care expert has been shown to decrease hospital and ICU patient lengths of stay and mortality.52,53 However, it is highly likely that in some areas, critical care experts will not be available locally. Telemedicine consultation in the aftermath of an MCC was first described > 25 years ago.54 Expert critical care telemedicine consult has been shown to improve best practice adherence, lower the rate of preventable complications,55 improve survival in sicker ICU patients,56 reduce hospital length of stay, and reduce ICU mortality in general (adjusted OR, 0.40; 95% CI, 0.31-0.52).55

Facilities that do not usually provide significant critical care should be prepared to manage patients in place for up to several days until transfer becomes possible. Hospitals that routinely provide critical care may also be challenged with populations that require more specialized care (pediatrics, burn, etc) because the usual receiving facilities for these patients become overwhelmed or incapacitated.

Within the United States, only 9.3% of the acute care hospitals provide pediatric critical care.57 Between 20% and 30% of the pediatric population lives > 50 miles from a hospital with a pediatric ICU, a level I or II trauma center, or a burn center.58 There is both state and regional variation in geographic access to burn centers in the United States, and routine referrals to a burn center may require hours of transport by ground or rotary air vehicles.59 Similar inequalities are described elsewhere.60,61 Under these circumstances, consultation with critical care experts at other facilities can contribute greatly to safe and effective in-place management.62 Key facilities should be identified and these relationships established prior to an event, including mechanisms to provide interregional consultation when required. Key supply and educational elements required to care for specialty populations should be identified and addressed preevent. For instance, baby formula and diapers for pediatric patients may be overlooked.24

Where critical care physicians are available, consultation and rounds may be modified and other services restricted (clinic, pulmonary, and other nonurgent testing) to provide care for critically ill patients. This may involve off-loading some physician responsibilities onto others. For example, hospitalists may provide most of the day-to-day management, whereas critical care physicians provide overall supervision and input for patients with worsening laboratory or physiologic parameters, complicated ventilator management issues, shock, or a requirement for emergency procedures.

Pharmacy Staff:

Medication errors account for more than three-fourths of serious medical errors that occur during normal ICU operations.63 During a disaster or pandemic, serious medication errors are likely to increase because of increased workload and medications from alternative supplies or with more than one brand name.64 Pharmacists play an important role on interdisciplinary ICU teams as medication safety experts.65 There is strong evidence substantiating reductions in adverse drug events when pharmacists are involved in the care of ICU patients.66 A two-tiered approach is advisable for the delivery of pharmacy services during an disaster or pandemic wherein pharmacists with critical care training and experience direct the efforts of less trained or experienced pharmacists and pharmacy technicians.25

Patient Flow and Distribution:

14. We suggest decisions regarding in-hospital placement of critically ill patients during an MCC (after initial survey and treatment) be performed by an experienced clinician who makes similar triage decisions on a daily basis.

15. Early discharge of ICU patients to the general ward is a complex process, requiring critical care expertise. To enable rapid admission of critically ill patients to the ICU immediately after termination of ED/operating room workup and treatment, we suggest discharge of ICU patients (when possible) during preparation for an impending MCC be given priority simultaneous to decisions made about initial ED patient distribution.

Triage during a pandemic or disaster is intended to provide the best care possible to as many patients as possible.67 Awareness of the existing resources and alternative resource options as well as prior experience in matching patients to resources enable optimization of resource use. Thus, professionals performing daily triage decisions are best equipped to optimize resource use during a disaster or pandemic. The selection and function of triage officers as well as the performance of triage are described in the “Triage” article by Christian et al68 in this consensus statement. Methods to avoid overtriage during a pandemic or disaster may include strict criteria to decrease admissions and facilitate discharges as well as cancellation of scheduled procedures. Reverse triage is the main tool used to open additional conventional ICU beds.69,70

Avoidance of Overtriage:

Imposing strict admission criteria has been shown to decrease overtriage. A relatively small reduction of sensitivity from ≥ 95%30 to 90%31-36 in field triage of individual patients can halve the volume of injured patients transported to level I trauma centers.71 Several large organizations thus have endorsed prehospital mass casualty triage tools,72,73 and rigorous triage criteria have been implemented successfully in field hospitals during MCC situations.74

However, during actual mass casualty events, triage systems often have not been applied and may not perform consistently as an isolated strategy to optimize the use of existing resources.75 The greatest benefit is gained from triage during a disaster or pandemic when it is performed by experienced providers. The Royal London trauma center experienced 33% overtriage from bombing sites where experienced helicopter emergency medical service providers functioned as triage officers vs 85% from other locations.43 Hence, it is important to include experienced critical care physicians in the patient distribution process in both accepting patients into and transferring them out of the ICU.

Service Deescalation and Engineered Failure:

Canceling scheduled procedures can provide staff and space for disaster and pandemic patients in operative and postoperative areas.76 However, canceling procedures can have potentially negative consequences for both the patients77 and the hospitals32,77-79 involved. Disasters may reach a point where the time and resources invested in certain treatments (eg, extracorporeal membrane oxygenation) are too great to continue to provide them because many more moderately injured patients can benefit from stabilization and prevention of complications than can benefit from advanced critical care interventions in the setting of severe organ failure.38 Deescalation and engineered failure are discussed in detail in the “Surge Capacity Principles” article by Hicks et al5 in this consensus statement.

Reverse Triage:

Reverse triage is the identification of patients for whom expedited discharge is safe and ethical. To enable immediate rapid admission of critically ill patients to the ICU in a disaster, discharge of ICU patients during preparation for impending MCC should be given priority simultaneously with decisions about initial ED patient distribution. Reverse triage can be a significant contributor to conservation of ICU surge capacity.69,70,80,81 In addition to the benefits of improved surge capacity, minimizing patient length of stay in the ED through more-rapid admission to the ICU may improve patient outcomes. Delays of > 6 h in transfer from the ED to the ICU have been associated with increased mortality (12.9%-17.4%) and length of hospital stay.82 Reverse triage requires preparation of relevant plans and procedures and a priori staff training.

Reverse triage may not be effective in all situations81; the more efficiently an ICU is run at baseline, the less reverse triage is likely to be beneficial or possible. Optimally, there should be daily evaluation of the potential for discharge to intermediate or floor-level care so that when a disaster occurs, a discharge list is already available. Availability of intermediate care and floor care beds is critical to the success of ICU reverse triage, and modifications of admission criteria to these units should be agreed on in advance to permit maximum flexibility in transfers and care delivery. The discretion of the critical care physician in these times is critical to safe and successful reverse triage.

Deployable Critical Care Services

16. We suggest deployable critical care services be considered a temporary alternative to critical care when loss of hospital infrastructure limits provision of critical care.

17. We suggest deployable critical care services are not definitive critical care facilities but may be used as a temporizing measure for delivery of critical care in a disaster/pandemic setting. Expansion of critical care resources in the hospital environment, with temporary facilities for lesser acuity patients, is preferred over provision of deployable critical care when possible.

18. We suggest deployable critical care services may serve as temporary critical care locations provided there is a clear plan for patient transfer, within a few hours to days, to a definitive treatment location.

19. In crisis surge response, we suggest less intensive treatment of moderately injured patients be prioritized over the deployment of temporary critical care services when it would result in improved outcomes for larger numbers of patients.

Deployable critical care services (eg, field hospitals) have traditionally been used by the military but have only recently been integrated into the civilian setting in response to disasters. Commonly described interventions in the civilian setting include surgical intervention, hemodialysis, and treatment of chronic diseases.83,84 Contrary to military field hospitals, which primarily focus on trauma, mobile hospitals, when deployed in the civilian setting, should prepare to manage a dynamic case mix that may include both surgical and nonsurgical patients as well as adult and pediatric populations.84 Nursing staff requirements may be higher than those required within a conventional medical facility.85 Organizational aspects may be adapted from the experience of professional organizations already working within specific specialties (eg, the Renal Disaster Relief Task Force established by the International Society of Nephrology).86-89

Although it is feasible to provide life support in an austere environment, such as a deployed facility, sophisticated critical care is most effectively provided in a tertiary-care hospital, with a number of supports such as consultant subspecialty physicians, interventional radiology, surgical services, microbiology, and laboratory services, among others. Life support without these other services and supports can at best be a temporary measure and will not ultimately serve patients well. Deployable critical care may be a packaged field hospital with advanced capabilities but could also include critical care expertise and materials inserted into a hospital structure deficient in these services (Fig 1).

Figure Jump LinkFigure 1 –  A and B, The sequence of surge during a disaster or pandemic illustrating that critical care services should be expanded within existing hospital facilities and that lower acuity patients should be transferred out to temporary facilities rather than attempting to provide critical care in field hospitals. (Adapted with permission from Rubinson et al.15)Grahic Jump Location

The most likely application of deployable critical care outside the military is in the use of limited surgical, dialysis, and other capabilities in an area that has a compromised health-care infrastructure; difficulty transferring patients out; and a large number of cases of crush or other orthopedic injury, such as had occurred in Haiti88,90 and after other massive earthquakes.9,83,91 Oxygen generation,92,93 potable water,94-96 water suitable for dialysis,97 power sources,31,98,99 infection control, and diagnostic support88,100 are all key limiting factors in the delivery of these types of services. Hospital infrastructure destruction and failure during disasters is common.30,31,101,102 Under these circumstances, the use of a deployable critical care facility or assets while awaiting evacuation of patients or awaiting infrastructure recovery is a reasonable temporary measure. Awareness of regional and national assets and their deployment time frame is critical for the success of these strategies.

Finally, during crisis circumstances in general and in disasters involving infrastructure compromise in particular, definitive care options for critically ill patients may become severely limited.103 When hospital resources are overwhelmed, delivery of critical care to a few consumes a disproportionately large part of hospital staff and supply resources. There may come a time when these resources would be better used for patient stabilization, care, and prevention of organ failure in a less seriously injured but larger group of patients. These decisions about triaging resources may affect select patients, treatments, or the entire ICU. Additional discussion is presented in the “Surge Capacity Principles” article by Hicks et al5 and “Triage” article by Christian et al68 in this consensus statement, with the ethical foundation for such decisions also addressed.38

Using Transportation Assets to Support Surge Response

20. We suggest surge capacity plans include predetermined standards that define minimal ongoing critical care capability in order to define the framework for decisions regarding patient transfer as the demands on the system gradually increase during a disaster or pandemic.

21. We suggest priority be given to transfer of assets to patients, particularly when transfer of patients to definitive care is limited by dangerous conditions (including considerable risk posed by available transportation options).

22. Transportation used for patient evacuations may also be used to bring in assets (eg, specialty providers and equipment), particularly when access/transport capacity is the limiting factor in patient movement.

Transportation and transfer of critically ill patients is addressed in the “Evacuation of the ICU” article by King et al104 in this supplement. Most ground and aeromedical transport platforms can only accommodate a single patient and although beneficial, require significant resources. There are also very few critical care transport-capable crews and units available in a given region. Even national assets designed for patient evacuation cannot provide true ongoing critical care to more than a few patients.105 In certain situations, appropriate personnel and equipment can safely provide ongoing care in nondedicated transport units, but there are significant issues with equipment not being designed for transfer and prehospital use and with training that may affect patient safety.

In addition, according to one estimate, about 7% of adult intensive care patients at any given time may be too ill to survive transport.106 Adverse events are common during critical patient transports, the most common being equipment malfunctions. Interhospital transport of critically ill patients has been associated with worse patient outcomes, particularly in pediatric populations.107

Given these risks, the scarcity of trained transport teams and vehicles for critical care transport, and the complex logistics involved in transporting critically ill patients, in many cases it may be better to bring resources to groups of patients rather than move large numbers of patients to the resources. The Task Force did not reach consensus regarding specific exclusions from this suggestion (eg, situations involving clear danger to patients or staff or infrastructure damage that would preclude continued delivery of critical care). However, bringing providers to unfamiliar facilities to work with unfamiliar equipment also poses risks that should be balanced against the advantages of continuing care in place. It is thus important to seek ways to augment the surge response through use of available transportation assets and concurrent planning for dual use of existing transport resources. Regional coordination of the movement of supplies, staff, and patients in these cases can be critical to success.

Demographic data of critical care requirements based on the overall population served, specific caseloads, and ICU cases and needs over time is an area that needs to be explored. Methodological assessment of achieved vs required surge would rely on standard ICU management report forms and data forms per patient. At the ICU management and institutional levels, forms based on the framework proposed for critical incident reporting could be used to study the events post hoc.108 For the individual patient, a well-known tool such as the Therapeutic Intervention Scoring System-28 could be initially converted into a required and provided checklist, with subsequent changes being made as experience is gained with data collection. Such forms would ensure uniform collection of data on the need for vs actual provision of ventilation and monitoring, ICU procedures, and consults. Until such evidence becomes available, careful analysis of community risks, facility role, and availability of regional resources should inform individual facility planning for surge capacity.

The critical care response to a disaster is more prolonged than the response in other sections of the hospital, which necessitates preplanning and training for staff augmentation and redistribution of resources. The limits of effective nurse-to-critical patient ratios in a disaster setting have yet to be elucidated, but lower ratios are clearly beneficial. Critical care physician oversight is crucial whether through direct or long-distance consult (eg, telemetry, telephone), particularly, but not only, for specialized critical care. Interregional consultation relationships should be established a priori to facilitate such consults.

Critical care surge relies on the principles of substitution, conservation, adaptation, reuse, and reallocation of resources. However, it also depends on the presence of stockpiles, ancillary services, and regional collaboration between facilities. Ventilators and their consumable supplies will be the limiting factor when critical care surge is required; thus, regional coalitions should outline operational plans and coordinate hospital efforts to achieve predetermined ventilation goals. Triage by an experienced provider, reverse triage, and service deescalation may all be used to minimize ICU resource consumption. In extreme crises, deescalation may mean prioritization of less advanced care to a greater number of individuals over delivery of critical care to a few. Until such decisions are made, during temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered a bridge to definite care. Despite the difficulties inherent to medical practice in such circumstances, it is generally better to convey resources to patients than vice versa.

Author contributions: S. E. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., R. K. K., N. K., J. R. D., A. V. D. and M. D. C. contributed to the development of PICO questions; S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., and R. K. K. conducted the literature review; S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., R. K. K., N. K., J. R. D., A. V. D., and M. D. C. contributed to development of expert opinion suggestion; S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., R. K. K., N. K., J. R. D., A. V. D., and M. D. C. contributed to the conception and design, or acquisition of data, or analysis and interpretation of data from the Delphi process; S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., and R. K. K. developed and drafted the manuscript; and N. K., J. R. D., A. V. D., and M. D. C. revised the manuscript critically for important intellectual content.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: Dr Einav has received grant funding unrelated to this consensus statement. Dr Hanfling serves as an anthrax consultant for GlaxoSmithKline. Mr Branson has received honoraria from Advanced Circulatory Systems Inc and Hamilton Medical totaling <$1,000 and received honoraria from IKARIA (manufacturer of inhaled nitric oxide) <$15,000 per year for technical support consulting. The remaining authors report no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Endorsements: This consensus statement is endorsed by the American Association of Critical-Care Nurses, American Association for Respiratory Care, American College of Surgeons Committee on Trauma, International Society of Nephrology, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Society of Hospital Medicine, World Federation of Pediatric Intensive and Critical Care Societies, World Federation of Societies of Intensive and Critical Care Medicine.

Role of sponsors: The American College of Chest Physicians was solely responsible for the development of these guidelines. The remaining supporters played no role in the development process. External supporting organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Further details on the Conflict of Interest Policy are available online at http://chestnet.org.

Other contributions: The views expressed within this article are solely those of the author (M. D. C.) and do not represent the official position or policy of the Royal Canadian Medical Service, Canadian Armed Forces, or the Department of National Defence.

Additional information: The e-Appendix can be found in the Supplemental Materials section of the online article.

Collaborators: Executive Committee: Michael D. Christian, MD, FRCPC, FCCP; Asha V. Devereaux, MD, MPH, FCCP, co-chair; Jeffrey R. Dichter, MD, co-chair; Niranjan Kissoon, MBBS, FRCPC; Lewis Rubinson, MD, PhD; Panelists: Dennis Amundson, DO, FCCP; Michael R. Anderson, MD; Robert Balk, MD, FCCP; Wanda D. Barfield, MD, MPH; Martha Bartz, MSN, RN, CCRN; Josh Benditt, MD; William Beninati, MD; Kenneth A. Berkowitz, MD, FCCP; Lee Daugherty Biddison, MD, MPH; Dana Braner, MD; Richard D Branson, MSc, RRT; Frederick M. Burkle Jr, MD, MPH, DTM; Bruce A. Cairns, MD; Brendan G. Carr, MD; Brooke Courtney, JD, MPH; Lisa D. DeDecker, RN, MS; COL Marla J. De Jong, PhD, RN [USAF]; Guillermo Dominguez-Cherit, MD; David Dries, MD; Sharon Einav, MD; Brian L. Erstad, PharmD; Mill Etienne, MD; Daniel B. Fagbuyi, MD; Ray Fang, MD; Henry Feldman, MD; Hernando Garzon, MD; James Geiling, MD, MPH, FCCP; Charles D. Gomersall, MBBS; Colin K. Grissom, MD, FCCP; Dan Hanfling, MD; John L. Hick, MD; James G. Hodge Jr, JD, LLM; Nathaniel Hupert, MD; David Ingbar, MD, FCCP; Robert K. Kanter, MD; Mary A. King, MD, MPH, FCCP; Robert N. Kuhnley, RRT; James Lawler, MD; Sharon Leung, MD; Deborah A. Levy, PhD, MPH; Matthew L. Lim, MD; Alicia Livinski, MA, MPH; Valerie Luyckx, MD; David Marcozzi, MD; Justine Medina, RN, MS; David A. Miramontes, MD; Ryan Mutter, PhD; Alexander S. Niven, MD, FCCP; Matthew S. Penn, JD, MLIS; Paul E. Pepe, MD, MPH; Tia Powell, MD; David Prezant, MD, FCCP; Mary Jane Reed, MD, FCCP; Preston Rich, MD; Dario Rodriquez, Jr, MSc, RRT; Beth E. Roxland, JD, MBioethics; Babak Sarani, MD; Umair A. Shah, MD, MPH; Peter Skippen, MBBS; Charles L. Sprung, MD; Italo Subbarao, DO, MBA; Daniel Talmor, MD; Eric S. Toner, MD; Pritish K. Tosh, MD; Jeffrey S. Upperman, MD; Timothy M. Uyeki, MD, MPH, MPP; Leonard J. Weireter Jr, MD; T. Eoin West, MD, MPH, FCCP; John Wilgis, RRT, MBA; ACCP Staff: Joe Ornelas, MS; Deborah McBride; David Reid; Content Experts: Amado Baez, MD; Marie Baldisseri, MD; James S. Blumenstock, MA; Art Cooper, MD; Tim Ellender, MD; Clare Helminiak, MD, MPH; Edgar Jimenez, MD; Steve Krug, MD; Joe Lamana, MD; Henry Masur, MD; L. Rudo Mathivha, MBChB; Michael T. Osterholm, PhD, MPH; H. Neal Reynolds, MD; Christian Sandrock, MD, FCCP; Armand Sprecher, MD, MPH; Andrew Tillyard, MD; Douglas White, MD; Robert Wise, MD; Kevin Yeskey, MD.

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Figures

Figure Jump LinkFigure 1 –  A and B, The sequence of surge during a disaster or pandemic illustrating that critical care services should be expanded within existing hospital facilities and that lower acuity patients should be transferred out to temporary facilities rather than attempting to provide critical care in field hospitals. (Adapted with permission from Rubinson et al.15)Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Primary Target Audiences for Suggestions
Table Graphic Jump Location
TABLE 2 ]  An Overview of the Critical Care Surge Planning Process

(Adapted from Christian et al6 and the Ontario Ministry of Health and Long-Term Care.7)

Table Graphic Jump Location
TABLE 3 ]  Suggested Ancillary Equipment for Surge Positive Pressure Ventilation