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

Special PopulationsSpecial Populations: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement FREE TO VIEW

David Dries, MD, MSE, FCCP; Mary Jane Reed, MD, FCCP; Niranjan Kissoon, MBBS, FRCPC; Michael D. Christian, MD, FRCPC, FCCP; Jeffrey R. Dichter, MD; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey S. Upperman, MD; on behalf of the Task Force for Mass Critical Care
Author and Funding Information

From HealthPartners Medical Group (Dr Dries), Stillwater, MN; University of Minnesota (Dr Dries), St. Paul, MN; Geisinger Medical Center (Dr Reed), Danville, PA; Temple School of Medicine (Dr Reed), Philadelphia, PA; BC Children’s Hospital and Sunny Hill Health Centre (Dr Kissoon), University of British Columbia, Vancouver, BC, Canada; Royal Canadian Medical Service (Dr Christian), Canadian Armed Forces and Mount Sinai Hospital, Toronto, ON, Canada; Allina Health (Dr Dichter), Minneapolis, MN; Aurora Healthcare (Dr Dichter), Milwaukee, WI; Sharp Hospital (Dr Devereaux), Coronado, CA; and Children’s Hospital Los Angeles (Dr Upperman), and Keck School of Medicine, University of Southern California, Los Angeles, CA.

CORRESPONDENCE TO: Mary Jane Reed, MD, FCCP, Department of Critical Care Medicine, Geisinger Medical Center, 100 North Academy Ave, Danville, PA 17822-2037; e-mail: Mj17820@gmail.com


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):e75S-e86S. doi:10.1378/chest.14-0737
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BACKGROUND:  Past disasters have highlighted the need to prepare for subsets of critically ill, medically fragile patients. These special patient populations require focused disaster planning that will address their medical needs throughout the event to prevent clinical deterioration. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients, including frontline clinicians, hospital administrators, and public health or government officials.

METHODS:  Key questions regarding the care of critically ill or injured special populations during disasters or pandemics were identified, and a systematic literature review (1985-2013) was performed. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. The panel did not include pediatrics as a separate special population because pediatrics issues are embedded in each consensus document.

RESULTS:  Fourteen suggestions were formulated regarding the care of critically ill and injured patients from special populations during pandemics and disasters. The suggestions cover the following areas: defining special populations for mass critical care, special population planning, planning for access to regionalized service for special populations, triage and resource allocation of special populations, therapeutic considerations, and crisis standards of care for special populations.

CONCLUSIONS:  Chronically ill, technologically dependent, and complex critically ill patients present a unique challenge to preparing and implementing mass critical care. There are, however, unique opportunities to engage patients, primary physicians, advocacy groups, and professional organizations to lessen the impact of disaster on these special populations.

Defining Special Populations for Mass Critical Care

1. We suggest the definition of special populations for mass critical care be those patients that may be at increased risk for morbidity and mortality outside a fully functional critical care environment or those patients that present unique challenges to providers when a full complement of supportive services is not available. We include the chronically ill and technologically dependent as the fragility of their baseline health puts them at significant risk for progression to a higher level of medical need.

Special Population Planning

2. We suggest critical care disaster planning include special populations.

3. We suggest professional societies, advocacy groups, governmental, and nongovernmental organizations be consulted when planning special population disaster preparedness and just-in-time care.

4. We suggest daily needs assessment of shelters include identification of those residents from special populations susceptible to decompensation to critical illness. A system to refer those identified to appropriate medical care should be in place.

5. We suggest disaster preparedness for special populations be part of their primary health-care maintenance. These patients should also be identified pre-event by their community (ie, nursing home facilities, health-care services, and social services providers) as an at-risk group for decompensation during a disaster and measures be taken to ensure they have a continuum of care during the event.

Planning for Access to Regionalized Services for Special Populations

6. We suggest identification of regionalized centers and establishment of communication be included in mass critical care planning.

7. We suggest regional specialized centers have mass disaster plans in place that include easily accessible, multidimensional, round-the-clock expertise available for consultation by local providers during mass critical care events.

8. Some special populations of mass critical care may require early transfer to specialized centers to maximize outcomes so should be identified early.

Triage and Resource Allocation of Special Populations

9. We suggest triage and resource allocation of special populations adhere to the same resource allocation strategy and process as the general population.

Therapeutic Considerations

10a. We suggest local, regional, and national critical care pharmacists and resources be identified during disaster preparedness.

10b. We suggest access to critical care or specialist pharmacists and resources include consideration for special populations such as those with burns, cirrhosis, organ transplant, and need for dialysis.

10c. We suggest pharmacists, especially those with critical care and specialty training, be an integral part of any mass critical care disaster team.

Crisis Standards of Care for Special Populations

11. We suggest research be conducted in crisis standard of care triggers for special populations that includes clinical, planning, and ethical domains across the life cycle of a disaster.

12. We suggest experts in the care of technology- and resource-dependent special populations convene to discuss and determine the acceptable parameters for crisis standards of care for a disaster.

Fifty-four million people with disabilities live in the United States,1,2 a group that is disproportionately vulnerable to disasters.3,4 In addition, many individuals have chronic health problems that are worsened by disaster conditions,5 particularly if they require supplemental oxygen, renal support, and mobility aids; are paralyzed; or are obese. These special populations are ill-defined, and planning for them is believed to be inadequate across a wide range of activities, pointing to a need for information to bolster disaster preparedness.6,7 Many issues that are potential barriers to care during a disaster have been identified.8-15

Apart from a shortage of intensive care beds and qualified ICU personnel,16 patients who require a high nursing-to-patient ratio, advanced technologic interventions, or extra supportive care may cause additional strain on the capability of the ICU to continue to provide care to existing patients as well as incoming patients. The suggestions in this article are important for all who care for special populations both before and after a disaster or pandemic occurs, including front-line clinicians, hospital administrators, and public health or government officials. Although it is important for all providers to be familiar with the potential implications for a disaster or pandemic on special populations, Table 1 provides an overview of the suggestions of most interest to each group.

Table Graphic Jump Location
TABLE 1 ]  Primary Target Audiences for Suggestions

The Special Populations topic panel identified 14 key questions in six areas, and literature searches were conducted for evidence to address these questions. An online resource for the key questions list was used, and corresponding search terms were identified. Literature searches were conducted for articles published from 1985 to 2013 to find evidence upon which to base recommendations. English-language articles were included, and non-English-language articles were reviewed and pertinent literature translated. Given the lack of high-quality data upon which to make evidence-based recommendations, expert opinion suggestions were developed with consensus achieved using a modified Delphi method. Full details regarding the methods used by the panel are provided in the “Methodology” article by Ornelas et al17 in this consensus statement.

Defining Special Populations for Mass Critical Care

1. We suggest the definition of special populations for mass critical care be those patients that may be at increased risk for morbidity and mortality outside a fully functional critical care environment or those patients that present unique challenges to providers when a full complement of supportive services is not available. We include the chronically ill and technologically dependent as the fragility of their baseline health puts them at significant risk for progression to a higher level of medical need.

Many definitions of special, vulnerable, or at-risk populations have been proposed. According to the US Department of Health and Human Services, the definition of special population, in the context of the National Response Framework and All Hazards Preparedness Act, is based on additional needs around the incident in one or more of the following areas: (1) maintaining independence, (2) communication, (3) transportation, (4) supervision, and (5) medical care. Governmental agencies often include children, elderly individuals, people with physical or emotional disabilities, individuals who live in institutionalized settings, poor people, or individuals with limited English proficiency. However, this broad definition does not lend itself to mass critical care. A special population as we have defined it for mass critical care is a vulnerable population that may be at increased risk for morbidity and mortality outside the norm of a critical care environment or those patients who present unique challenges when a full complement of supportive services is not available (Table 2). Other populations germane to mass critical care would include those with significant chronic medical conditions and who depend on technology (Table 3). Our definition of special populations does not include the general pediatric population because children are a core component of all communities affected by pandemics and disasters in proportion to their presence in the local population. However, children who have special needs and depend on technology are included here.

Table Graphic Jump Location
TABLE 2 ]  Community Populations Susceptible to Decompensation to Critical Illness in Disaster Environments and Potential Barriers to Successful Disaster Care9-16

ICD = implantable cardioverter defibrillator; LVAD = left ventricular assist device; NIV = noninvasive ventilation.

a 

Community, chronically ill, and medically fragile.

Table Graphic Jump Location
TABLE 3 ]  Critical Care Patient Populations That May Be Vulnerable When Full Critical Care Services Curtailed or Not Available

CRRT = continuous renal replacement therapy; ECLS = extracorporeal life support; HFOV = high-frequency oscillatory ventilation; IABP = intraaortic balloon pump; ICP = intracranial pressure; IRDS = infant respiratory distress syndrome; PAPR = powered air purifying respirator; PEEP = positive end-expiratory pressure. See Table 2 legend for expansion of other abbreviation.

Special Population Planning

2. We suggest critical care disaster planning include special populations.

Special populations suffered higher morbidity and mortality during recent disasters and have led governmental and nongovernmental organizations to include this group in disaster planning. For example, during Hurricane Katrina, 75% of all deaths occurred among elderly people, who comprised only 15% of the affected population. Forty-four percent of > 600 patients on chronic dialysis missed at least one session, and 17% missed three or more sessions with a concomitant increase in hospitalization postdisaster.18

3. We suggest professional societies, advocacy groups, governmental, and nongovernmental organizations be consulted when planning special population disaster preparedness and just-in-time care.

4. We suggest daily needs assessment of shelters include identification of those residents from special populations susceptible to decompensation to critical illness. A system to refer those identified to appropriate medical care should be in place.

5. We suggest disaster preparedness for special populations be part of their primary health-care maintenance. These patients should also be identified pre-event by their community (ie, nursing home facilities, health-care services, and social services providers) as an at-risk group for decompensation during a disaster and measures be taken to ensure they have a continuum of care during the event.

One example of disaster preparedness and care of a specific vulnerable population is the Kidney Community Emergency Response Coalition (KCER), a combined effort of private, professional, and governmental stakeholders. KCER provides disaster preparedness education for patients and dialysis networks as well as for disaster response. Internationally, the Renal Disaster Relief Task Force, an initiative of the International Society of Nephrology, provides just-in-time care and expert resources postevent.18-23 A similar model can be adopted for other special needs, such as oxygen therapy, with primary care providers, home health professionals, vendors, and advocacy groups.24-30

Planning for Access to Regionalized Services for Special Populations

6. We suggest identification of regionalized centers and establishment of communication be included in mass critical care planning.

7. We suggest regional specialized centers have mass disaster plans in place that include easily accessible, multidimensional, round-the-clock expertise available for consultation by local providers during mass critical care events.

8. Some special populations of mass critical care may require early transfer to specialized centers to maximize outcomes so should be identified early.

Regionalization of specialized care is increasing as designated trauma centers, pediatric hospitals, and burn centers are becoming more commonplace. Regionalization to specialized centers decreases costs, alleviates the need for local stockpiling of specialized supplies, concentrates expertise, and may decrease morbidity and mortality.31 However, the ability of the regional center to accept mass critical care special populations may be limited because many of these centers run at near capacity normally. For example, burns require specific expertise within the first few days to have the best outcome. The approximate 1,800 burn beds in the United States run at 95% capacity.32 Understanding this limitation has led specialty centers to develop regional burn disaster plans that accommodate transfers and are a resource for just-in-time care.31-33 Use of websites and mobile phone applications of guidelines has also been suggested and developed worldwide.33 BurnMed (developed by The Johns Hopkins University) and MBC Burn Care (developed by the Euro-Mediterranean Council for Burns and Fire Disasters) are two examples of mobile applications for burn care.

Triage and Resource Allocation of Special Populations

9. We suggest triage and resource allocation of special populations adhere to the same resource allocation strategy and process as the general population.

Societal norms, whether by moral, ethical standards or legislation, mandate that individuals be treated equally and not influenced by disability, race, gender, perceived value to society, age, creed, culture, or resource. In mass critical care, triage and resource allocation should be based on triage guidelines for the general population as outlined in the “Triage” article by Christian et al34 and “Ethical Considerations” article by Daugherty Biddison et al35 in this consensus statement.

Therapeutic Considerations

10a. We suggest local, regional, and national critical care pharmacists and resources be identified during disaster preparedness.

10b. We suggest access to critical care or specialist pharmacists and resources include consideration for special populations such as those with burns, cirrhosis, organ transplant, and need for dialysis.

10c. We suggest pharmacists, especially those with critical care and specialty training, be an integral part of any mass critical care disaster team.

Local Pharmacist Disaster Response Teams have been developed along with integration of National Pharmacy Response Teams as part of the US Department of Health and Human Services National Disaster Medical System response teams. The American Society of Health-System Pharmacists has committed to help maintain emergency preparedness and just-in-time care, including maintenance of an electronic communications network of hospital pharmacy department directors that can be used to transmit urgent information related to emergency preparedness.36,37 The mass critical care special population pharmaceutical challenges include, but are not limited to, (1) varied volumes of distribution, (2) altered or changing kinetics, (3) multiple drug interactions, (4) dosing challenges, (5) antimicrobial resistance, and (6) frequent drug order changes. Including pharmacists and identification of and access to critical care pharmacist resources during disasters, even remotely, is important to the care of special populations.36,37

Crisis Standards of Care for Special Populations

11. We suggest research be conducted in crisis standard of care triggers for special populations that includes clinical, planning, and ethical domains across the life cycle of a disaster.

12. We suggest experts in the care of technology- and resource-dependent special populations convene to discuss and determine the acceptable parameters for crisis standards of care for a disaster.

No data directly prove that transitioning to a crisis standard of care is the preferred method for preserving limited resources for special needs populations. Several publications discuss the general issues surrounding the use of crisis standards of care when resources are limited, but these discussions do not directly address outcomes, such as morbidity or mortality.38,39

An example of implementation of a crisis standard of care occurred on the US Naval Ship Comfort during the aftermath of the Haitian earthquake on January 12, 2010. Having the only dialysis capability for the country after the earthquake, the influx of patients with renal failure and crush injuries stretched the dialysis capabilities onboard the 1,000-bed hospital ship. This prompted a dialyzer reuse protocol. Patient-designated dialysis filters were cleaned between treatments and reused for each patient. Priority was given to those with oliguric renal failure. Hyperkalemia was treated with bicarbonate-based IV fluids, oral binding agents, IV calcium, insulin, and glucose. Dual-lumen catheters were not available; therefore, separate central venous cannulae were used.40 There did not appear to be any long-term sequelae of this approach. It would be advantageous to have professional societies and stakeholders in the care of the special populations outlined in this article develop crisis standard of care guidelines based on the Institute of Medicine’s tenets.41

There is a paucity of research evidence to direct care for special populations during mass critical care, leaving recommendations based on expert opinion and small case series. Patients on dialysis appear to have an advantage in disaster planning because hemodialysis is done in registered centers and long-term patients can be tracked. This has allowed governmental, professional, and advocacy groups to develop a proactive and reactive support network during disasters. A central data bank of patients with chronic diseases who require homogenous treatment, such as oxygen supplementation, would help governmental, advocacy, and professional society stakeholders to streamline care during a disaster as would the development of crisis standard of care guidelines for mass critical care of special populations.

Medically fragile and chronically ill patients need to be preidentified and considered during disaster planning. Preparation on all levels is necessary to mitigate a disaster’s impact on this population who will likely decompensate and may need scarce critical care resources. The model offered by KCER is a template that may prove useful in other special populations.

Author contributions: M. J. R. 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. D. D., M. J. R., N. K., M. D. C., J. R. D., A. V. D., and J. S. U. contributed to the development of PICO questions; D. D., M. J. R., and J. U. conducted the literature review; D. D., M. J. R., N. K., M. D. C., J. R. D., A. V. D., and J. S. U. contributed to development of expert opinion suggestion; D. D., M. J. R., N. K., M. D. C., J. R. D., A. V. D., and J. S. U. contributed to the conception and design, or acquisition of data, or analysis and interpretation of data from the Delphi process; D. D., M. J. R., and J. S. U. developed and drafted the manuscript; and N. K., M. D. C., J. R. D., and A. V. D. revised the manuscript critically for important intellectual content.

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.

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 opinions expressed within this manuscript 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.

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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Yurt RW, Lazar EJ, Leahy NE, et al. Burn disaster response planning: an urban region’s approach. J Burn Care Res. 2008;29(1):158-165. [PubMed]
 
Christian MD, Sprung CL, King MA, et al; on behalf of the Task Force for Mass Critical Care. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e61S-e74S.
 
Daugherty Biddison L, Berkowitz KA, Courtney B, et al; on behalf of the Task Force for Mass Critical Care. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e145S-e155S. [CrossRef] [PubMed]
 
ASHP statement on the role of health-system pharmacists in emergency preparedness. ASHP website. http://www.ashp.org/DocLibrary/BestPractices/SpecificStEmergPrep.aspx. Accessed October 15, 2013.
 
Public Health Emergency website. http://www.phe.gov/Preparedness/responders/ndms/Pages/default.aspx. Accessed October 16, 2013.
 
Schultz CH, Annas GJ. Altering the standard of care in disasters—unnecessary and dangerous. Ann Emerg Med. 2012;59(3):191-195. [CrossRef] [PubMed]
 
Koenig KL, Lim HCS, Tsai S-H. Crisis standard of care: refocusing health care goals during catastrophic disasters and emergencies. J Exp Clin Med. 2011;3(4):159-165. [CrossRef]
 
Amundson DE, Dadekian G, Etienne M, et al. Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian Earthquake. Ann Intern Med. 2010;152(11):733-737. [CrossRef] [PubMed]
 
Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations – Letter Report. Washington, DC: Institute of Medicine, National Academies of Science; 2009.
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  Primary Target Audiences for Suggestions
Table Graphic Jump Location
TABLE 2 ]  Community Populations Susceptible to Decompensation to Critical Illness in Disaster Environments and Potential Barriers to Successful Disaster Care9-16

ICD = implantable cardioverter defibrillator; LVAD = left ventricular assist device; NIV = noninvasive ventilation.

a 

Community, chronically ill, and medically fragile.

Table Graphic Jump Location
TABLE 3 ]  Critical Care Patient Populations That May Be Vulnerable When Full Critical Care Services Curtailed or Not Available

CRRT = continuous renal replacement therapy; ECLS = extracorporeal life support; HFOV = high-frequency oscillatory ventilation; IABP = intraaortic balloon pump; ICP = intracranial pressure; IRDS = infant respiratory distress syndrome; PAPR = powered air purifying respirator; PEEP = positive end-expiratory pressure. See Table 2 legend for expansion of other abbreviation.

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Christian MD, Sprung CL, King MA, et al; on behalf of the Task Force for Mass Critical Care. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e61S-e74S.
 
Daugherty Biddison L, Berkowitz KA, Courtney B, et al; on behalf of the Task Force for Mass Critical Care. Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e145S-e155S. [CrossRef] [PubMed]
 
ASHP statement on the role of health-system pharmacists in emergency preparedness. ASHP website. http://www.ashp.org/DocLibrary/BestPractices/SpecificStEmergPrep.aspx. Accessed October 15, 2013.
 
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Schultz CH, Annas GJ. Altering the standard of care in disasters—unnecessary and dangerous. Ann Emerg Med. 2012;59(3):191-195. [CrossRef] [PubMed]
 
Koenig KL, Lim HCS, Tsai S-H. Crisis standard of care: refocusing health care goals during catastrophic disasters and emergencies. J Exp Clin Med. 2011;3(4):159-165. [CrossRef]
 
Amundson DE, Dadekian G, Etienne M, et al. Practicing internal medicine onboard the USNS COMFORT in the aftermath of the Haitian Earthquake. Ann Intern Med. 2010;152(11):733-737. [CrossRef] [PubMed]
 
Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations – Letter Report. Washington, DC: Institute of Medicine, National Academies of Science; 2009.
 
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