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CHEST publishes select peer-reviewed, accepted manuscripts Online First each week. The media embargo is lifted on the date of Online First publication. Final, edited versions will appear in a numbered issue of CHEST and may contain substantive changes. We encourage readers to check back for the final article. Online First papers are indexed in PubMed and by search engines, but the information, including the final title and author list, may be updated on final publication.

original research 
Arendina W. van der Kooi, PhD; Irene J. Zaal, MD; Francina A. Klijn, MD; Huiberdina L. Koek, MD, PhD; Ronald C. Meijer, MD; Frans S. Leijten, MD, PhD; Arjen J. Slooter, MD, PhD
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Background:  Despite its frequency and impact, delirium is poorly recognized in postoperative- and critically ill patients. EEG (electroencephalography) is highly sensitive to delirium, but as currently used, it is not diagnostic. To develop an EEG-based tool for delirium detection with a limited number of electrodes, we determined the optimal electrode derivation and EEG characteristic in order to discriminate delirium from non-delirium.

Methods:  Standard EEGs were recorded in 28 delirious and 28 age- and sex-matched non-delirious post-cardiothoracic surgery patients, as classified by experts using Diagnostic and Statistical Manual of mental disorders-IV criteria. The first minute of artifact-free EEG data with eyes-closed as well as with eyes-open was selected. For each derivation, six EEG parameters were evaluated. Using Mann-Whitney U-tests, all combinations of derivations and parameters were compared between delirious and non-delirious patients. Corresponding p-values, corrected for multiple testing, were ranked.

Results:  The largest difference between patients with and without delirium and highest area under the receiver operating curve (0.99; 95% confidence interval: 0.97-1.00) was found during eyes-closed, using electrode derivation F8-Pz (frontal-parietal) and relative delta power (Median (Inter Quartile Range) delirium=0.59 (0.47-0.71); non-delirium=0.20 (0.17-0.26); p=1.8*10-12). With a cut-off value of 0.37, it resulted in a sensitivity of 100% (95% confidence interval: 100%-100%) and specificity of 96% (95% confidence interval: 88%-100%).

Conclusions:  In a homogenous population of non-sedated cardiothoracic surgery patients, we observed that relative delta power from an eyes-closed EEG recording with only two electrodes in a frontal-parietal derivation can distinguish post-cardiothoracic surgery patients with delirium from those without.

original research 
S Tomassetti; C Gurioli; JH Ryu; PA Decker; C Ravaglia; P Tantalocco; M Buccioli; S Piciucchi; N Sverzellati; A Dubini; G Gavelli; M Chilosi; V Poletti
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BACKGROUND  Lung cancer (LC) is frequently associated with idiopathic pulmonary fibrosis (IPF), despite this well-known association the outcome of LC in IPF patients is unclear. The objective of this study was to evaluate the impact of LC on survival of patients with associated IPF.

METHODS  A total of 260 patients with IPF were reviewed and 186 IPF cases had complete clinical and follow-up data. Among these 5 cases were excluded because LC was radiologically suspected but not histologically proven. The remaining 181 cases were categorized in two groups: 23 patients with biopsy proven LC and IPF (LC-IPF) and 158 patients with IPF only (IPF). Survival and clinical characteristics of the two groups were compared.

RESULTS  Prevalence of histologically proven LC was 13%, and among those with LC-IPF cumulative incidence at 1 and 3 years was 41% and 82%. Patients with LC were more frequently smokers (91.3% vs 71.6%, p= 0.001), with combined pulmonary fibrosis and emphysema (CPFE) (52% vs 32%, p = 0.052). Survival in patients with LC-IPF was significantly worse than IPF patients without LC (median survival 38.7 months versus 63.9 months (HR=5.0; 95% CI: 2.91-8.57; p<0.001). Causes of death in the study group were respiratory failure in 43% of patients, LC progression in 13 % and LC treatment related complications in 17%.

CONCLUSION  In patients with IPF LC has a significant adverse impact on survival. Diagnosis and treatment of LC in IPF are burdened by an increased incidence of severe complicating events, apparently as lethal as the cancer itself.

original research 
Deena Kelly Costa, PhD, RN; David J. Wallace, MD, MPH; Amber E. Barnato, MD, MPH, MS; Jeremy M. Kahn, MD, MS
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Background:  Intensive care units (ICUs) are increasingly staffed with nurse practitioners/ physician assistants (NP/PAs) but it is unclear how they influence quality of care. We examined the association between NP/PA staffing and in-hospital mortality for ICU patients.

Methods:  We used retrospective cohort data from the 2009-2010 Acute Physiology and Chronic Health Evaluation clinical information system and an ICU-level survey. We included patients (≥ 17 years of age) admitted to one of 29 adult medical and mixed medical-surgical ICUs in 22 U.S. hospitals. Since our survey could not assign NP/PAs to individual patients, the primary exposure was admission to an ICU where NP/PAs participated in patient care. The primary outcome was patient level in-hospital mortality. We used multivariable relative risk regression to examine the effect of NP/PAs on in-hospital mortality, accounting for differences in case-mix, ICU characteristics and clustering of patients within ICUs. We also examined this relationship in subgroups: patients on mechanical ventilation, patients with the highest quartile of Acute Physiology Score (>55), ICUs with low intensity physician staffing and with physician trainees.

Results:  21 (72.4%) ICUs had NP/PAs. Patients in ICUs with NP/PAs had lower mean Acute Physiology Scores (42.4 vs. 46.7 p<0.001), and mechanical ventilation rates (38.8% vs. 44.2%, p<0.001) than ICUs without NP/PAs. Unadjusted and risk-adjusted mortality were similar between groups [adjusted relative risk: 1.10, (95% CI: 0.92, 1.31)]. This result was consistent in all examined subgroups.

Conclusions:  NP/PAs appear to be a safe adjunct to the ICU team, supporting NP/PA management of the critically ill.

original research 
Angelo M. Taveira-DaSilva, M.D., Ph.D.; Amanda M. Jones, C.R.N.P.; Patricia Julien-Williams, C.R.N.P.; Mario Stylianou, Ph.D.; Joel Moss, M.D., Ph.D.
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Background.  Combined simvastatin and sirolimus therapy reduce TSC2-null lesions and alveolar destruction in a mouse model of lymphangioleiomyomatosis (LAM), suggesting that therapy with both drugs may benefit LAM patients.

Methods.  To determine whether simvastatin changed the prevalence of adverse events or altered the therapeutic effects of sirolimus, we recorded adverse events and changes in lung function in LAM patients treated with simvastatin plus sirolimus (n=14), sirolimus (n=44), or simvastatin (n=20).

Results.  Sirolimus-related adverse events in the simvastatin plus sirolimus, and sirolimus only groups, were 64 and 66 % for stomatitis, 50 and 52 % for diarrhea, 50 and 45 % for peripheral edema, 36 and 61 % for acne, 36 and 30 % for hypertension, 29 and 27 % for proteinuria, 29 and 27 % for leukopenia, and 21 and 27 % for hypercholesterolemia. The frequency of simvastatin-related adverse events in the simvastatin, and simvastatin plus sirolimus groups were 60 and 50 % for arthralgias, and 35 and 36 % for myopathy. Before simvastatin plus sirolimus therapy, FEV1 and DLCO yearly rates of change were respectively, -1.4±0.2 and -1.8±0.2 % predicted. After simvastatin plus sirolimus therapy, these rates changed to +1.2±0.5 (p=0.635) and +0.3±0.4 % predicted, respectively (p=0.412). In 44 patients treated with sirolimus alone, FEV1 and DLCO rates of change were -1.7±0.1 and -2.2±0.1 % predicted before treatment, and +1.7±0.3 and +0.7±0.3 % predicted after therapy (p<0.001).

Conclusions.  Therapy with sirolimus and simvastatin does not increase the prevalence of drug adverse events or alter the therapeutic effects of sirolimus.

editorials  FREE TO VIEW
Christian Sandrock, MD, MPH, FCCP
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  The critically ill are a unique group of patients in disaster response as they require resource-intensive care, need advanced and costly therapies, and require specialized settings and providers to deliver this care(1-2). They can present with a sudden surge of patients over a short period of time, pushing the limits of the healthcare facility, or they can present over a sustained period of time, such as the 2009 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 a sustained intensive response, thus presenting varying response needs throughout the disaster(2-3). This variability with the critically ill creates uncertainty in the healthcare response, as local, regional, and national healthcare systems may have resource limitations, a paucity of medical expertise, and structural compromise to healthcare clinics and hospitals in 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 extent to the critically ill, planning for this uncertainty in mass critical care is paramount for ensuring good patient outcomes(3-5).

evidence-based medicine  FREE TO VIEW
Michael D. Christian, MD, MSc, FCCP, FRCP(C); Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Lewis Rubinson, MD, PhD; Niranjan Kissoon, MBBS, FRCP(C), FAAP, FCCM, FACPE on behalf of the Task Force for Mass Critical Care
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  Natural disasters, industrial accidents, terrorism attacks and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients including front line clinicians, hospital administrators, professional societies and public health or government officials. In 2008 the American College of Chest Physician’s (ACCP) Task Force on Mass Critical Care published its first series of disaster critical care suggestions. The Task Force for Mass Critical Care was reconvened with expanded scope and expertise to provide an evidence-informed, rigorously developed set of usable recommendations to critical care providers throughout the world. In this iteration we have made a number of attempts to bolster the expertise of the Task Force itself as well as utilized a more rigorous methodology to develop the suggestions.

  Task Force executive committee members identified core topic areas regarding the provision of care to critically ill or injured patients from pandemics or disasters and subsequently assembled an international panel for each identified area. The current Task Force included a total of 100 participants from 9 countries, comprised of clinicians and experts from a wide variety of disciplines. The international disaster medicine experts were brought together to identify key questions (in a PICO-based format) within each of the core topics areas. Comprehensive literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions that are presented in this supplement utilizing a modified Delphi process. A total of 315 suggestions were drafted across all topic groups. After two rounds of a Delphi consensus-development process, 267 suggestions were chosen by the panel to include in the document and published in a total of twelve manuscripts comprising the core chapters of this supplement.

  The ultimate aim of the supplement is to expand the focus beyond the walls of intensive care units (ICU) to provide recommendations for the management of all critically ill or injured adults and children resulting from a disaster or pandemic wherever that care may be provided. Considerations for the management of critically ill patients include clinical priorities and logistics (supplies, evacuation, and triage) as well as the key enablers (systems planning, business continuity, legal framework, and ethical considerations) that facilitate the provision of this care. The supplement also aims to illustrate how the concepts of mass critical care are integrated across the spectrum of surge events from conventional through contingency to crisis standards of care.

evidence-based medicine  FREE TO VIEW
Joe Ornelas, MS; Jeffrey R. Dichter, MD; Asha V. Devereaux, MD, MPH, FCCP; Niranjan Kissoon, MBBS; Alicia Livinski, MA, MPH; Michael D. Christian, MD, MSc, FRCPC, FCCP on behalf of the Task Force for Mass Critical Care
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Background:  Natural disasters, industrial accidents, terrorism attacks and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients including front line clinicians, hospital administrators, professional societies and public health or government officials. The field of disaster medicine does not have the required body of evidence needed to undergo a traditional guideline development process. In result, consensus statement development methodology was employed to capture the highest caliber expert opinion in a structured, scientific approach.

Methodology:  Task Force executive committee members identified core topic areas regarding the provision of care to critically ill or injured patients from pandemics or disasters and subsequently assembled an international panel for each identified area. International disaster medicine experts were brought together to identify key questions (in a PICO-based format) within each of the core topics areas. A comprehensive literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions that are presented in this supplement utilizing a modified Delphi process.

Results:  A total of 315 suggestions were drafted across all topic groups. After two rounds of a Delphi consensus-development process, 267 suggestions were chosen by the panel to include in the document and published in a total of twelve manuscripts comprising the core chapters of this supplement. Drafts manuscripts were prepared by the topic editors and members of the working groups for each of the topics producing a total of eleven papers. Once the preliminary drafts were received, the executive committee (writing committee) then met to review, edit, and promote alignment of all of the primary drafts of the manuscripts prepared by the topic editors and their groups. The topic editors then revised their manuscripts based on the executive committee’s edits and comments. The writing committee subsequently reviewed the updated drafts and prepared the final manuscripts for submission to the GOC. The manuscripts subsequently underwent review by the GOC including external review as well as peer-review for the journal publication. The writing committee received the feedback from the reviewers and modified the manuscripts as required.

Conclusions:  Based on a robust and transparent process, this project utilized rigorous methodology to produce clinically relevant, trustworthy consensus statements, with the aim to provide needed guidance on treatment and procedures for practitioners, hospital administrators, and public health and government officials when addressing the care of critically ill or injured patients in disasters or pandemics.

evidence-based medicine  FREE TO VIEW
John L. Hick, MD; Sharon Einav, MD; Dan Hanfling, MD; Niranjan Kissoon, MBBS; Jeffrey R. Dichter, MD; Asha V. Devereaux, MD, MPH, FCCP; Michael D. Christian, MD, MSc, FRCPC, FCCP on behalf of the Task Force for Mass Critical Care
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Background:  This paper provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disaster or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion paper addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. [See Surge Capacity Logistics article in this supplement]. The suggestions in this chapter are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients including front line clinicians, hospital administrators, and public health or government officials.

Methods:  The Surge Capacity 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 evidence on which to base key suggestions. Most reports were small-scale, observational, or used flawed modeling and hence the level of evidence on which to base recommendations was poor, therefore not permitting the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel.

Results:  This paper presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care including: the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service de-escalation (also considered as ”engineered failure”).

Conclusions:  Future reports of critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and utilized in disaster events.

evidence-based medicine  FREE TO VIEW
Sharon Einav, MD; John L. Hick, MD; Dan Hanfling, MD; Brian L. Erstad, PharmD, FCCM; Eric S. Toner, MD; Richard D. Branson, MSc, RRT; Robert K. Kanter, MD; Niranjan Kissoon, MBBS; Jeffrey R. Dichter, MD; Asha V. Devereaux, MD, MPH, FCCP; Michael D. Christian, MD, MSc, FRCPC, FCCP on behalf of the Task Force for Mass Critical Care
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Introduction:  Successful management of a disaster or pandemic requires implementation of pre-existing 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 chapter are important for all of those involved in a large-scale disaster or pandemic including front line clinicians, hospital administrators, and public health or government officials. Specifically, this paper focuses on surge logistics, those elements that provide the capability to deliver mass critical care.

Methodology:  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 screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, observational or used flawed modeling and hence the level of evidence on which to base recommendations was poor therefore not permitting the development of evidence based recommendations. The Surge Capacity panel subsequently followed the American College of Chest Physician’s (ACCP) Guidelines Oversight Committee’s methodology to develop expert opinion suggestions utilizing a modified Delphi process.

Results:  This paper presents 22 suggestions pertaining to surge capability 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 use of transportation assets to support the surge response.

Conclusions:  Critical care response to a disaster relies careful planning for staff and resource augmentation and involves many agencies. Maximizing 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 pre-determined goals. Specialized physician oversight is necessary and if not available on site it may be provided through remote consultation. Triage by experienced providers, reverse triage, and service de-escalation may be used to minimize ICU resource consumption. During temporary loss of infrastructure or overwhelming of hospital resources, deployable critical care services should be considered.

evidence-based medicine  FREE TO VIEW
Mary A. King, MD, MPH, FCCP; Alexander S. Niven, MD, FCCP; William Beninati, MD; Ray Fang, MD; Sharon Einav, MD; Lewis Rubinson, MD, PhD; Niranjan Kissoon, MBBS; Asha V. Devereaux, MD, MPH, FCCP; Michael D. Christian, MD, MSc, FRCPC, FCCP; Colin K. Grissom, MD, FCCP on behalf of the Task Force for Mass Critical Care
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Background:  Despite the high risk for patient harm during unanticipated intensive care unit (ICU) evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this chapter are important for all who are involved in disasters or pandemics with multiple critically ill or injured patients including front line clinicians, hospital administrators and public health or government officials.

Methodology:  The Evacuation and Mobilization panel utilized the American College of Chest Physician’s (ACCP) Guidelines Oversight Committee’s methodology to develop 7 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process.

Results:  Based on current best evidence, we provide thirteen suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Inter- and intra-hospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation, are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System (HICS). A 3-stage ICU evacuation timeline including 1) No Immediate Threat, 2) Evacuation Threat, and 3) Evacuation Implementation should be used. Detailed suggestions on ICU evacuation including: regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information/tracking, and Federal and international evacuation assistance systems are also provided.

Conclusions:  Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers. Critical care providers have a professional obligation to become better educated, prepared, and engaged with the processes of ICU evacuation in order to provide a safe continuum of critical care during a disaster.

evidence-based medicine  FREE TO VIEW
Michael D. Christian, MD, MSc, FRCPC, FCCP; Charles L. Sprung, MD, MCCP; Mary A. King, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Niranjan Kissoon, MBBS; Asha V. Devereaux, MD, MPH, FCCP; Charles D. Gomersall, BSc, MBBS on behalf of the Task Force for Mass Critical Care
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Background:  Disasters and pandemics can result in large numbers of critically ill or injured patients that may overwhelm available resources despite implementing surge response strategies. If this occurs, critical care triage, which includes both prioritizing patients for care and rationing scarce resources, will be required. The suggestions in this chapter are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients including front line clinicians, hospital administrators and public health or government officials.

Methods:  The triage work group reviewed previous task force suggestions and the literature to identify 17 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process. Suggestions from the previous task force that were not being updated were also included for validation by the expert panel.

Results:  The suggestions from the task force outline the key principles upon which critical care triage should be based as well as a path for the development of the plans, processes, and infrastructure required. This chapter provides eleven suggestions regarding the principles upon which critical care triage should be based and policies to guide critical care triage.

Conclusions:  Ethical and efficient critical care triage is a complex process that requires significant planning and preparation. At present, the prognostic tools required to produce an effective decision support system (triage protocol) as well as the infrastructure, processes, legal protections, and training are largely lacking in most jurisdictions. Therefore, critical care triage should be a last resort after mass critical care surge strategies.

evidence-based medicine  FREE TO VIEW
David J. Dries, MD; Mary Jane Reed, MD, FCCP; Niranjan Kissoon, MBBS; Michael D. Christian, MD, MSc, FRCPC, FCCP; Jeffrey R. Dichter, MD; Asha Devereaux, MD, MPH, FCCP; Jeffrey S. Upperman, MD, FAAP, FACS on behalf of the Task Force for Mass Critical Care
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Background  Past disasters have highlighted the need to prepare for subsets of those critically ill medically fragile patients. These chronic, medically fragile patients require focused disaster planning that will address their medical needs throughout the event in order to prevent clinical deterioration. The suggestions in this chapter are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients including front line clinicians, hospital administrators and public health or government officials.

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

Results:  Fourteen suggestions were formulated regarding the care of the critically ill and injured from special populations during disasters and pandemics. 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:  The 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.

evidence-based medicine  FREE TO VIEW
Jeffrey R. Dichter, MD; Robert K. Kanter, MD; David J. Dries, MD; Valerie A. Luyckx, MD; Matthew L. Lim, MD; John Wilgis, MD; Michael R. Anderson, MD; Babak Sarani, MD; Nathaniel Hupert, MD; Ryan Mutter, PhD; Asha V. Devereaux, MD, MPH, FCCP; Michael D. Christian, MD, MSc, FRCPC, FCCP; Niranjan Kissoon, MBBS on behalf of the Task Force for Mass Critical Care
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Background:  Systems level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning systems level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for systems planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a disaster or pandemic with multiple critically ill or injured patients including front line clinicians, hospital administrators, and public health or government officials.

Methodology:  The ACCP consensus statement development process was followed in developing suggestions. Task force members met in person to develop 9 key questions thought to be most relevant for systems planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process.

Results:  Suggestions were developed and grouped according to the following thematic elements: 1) National government support of healthcare coalitions/Regional Health Authorities; 2) Teamwork within healthcare coalitions and Regional Health Authorities; 3) Systems level communication; 4) System level surge capacity and capability; 5) Pediatric patients and special populations; 6). Healthcare coalitions, Regional Health Authorities and networks: 7). Models of advanced regional care systems: and 8) The use of simulation for preparedness and planning.

Conclusions:  Systems level planning is essential to provide care for large numbers of critically ill patients due to disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from healthcare institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

evidence-based medicine  FREE TO VIEW
Pritish K. Tosh, MD; Henry Feldman, MD; Michael D. Christian, MD, MSc, FRCPC, FCCP; Asha V. Devereaux, MD, MPH, FCCP; Niranjan Kissoon, MBBS; Jeffrey R. Dichter, MD on behalf of the Task Force for Mass Critical Care
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Background:  During disasters supply chain vulnerabilities such as power, transportation and communication may affect the delivery of medications and medical supplies, and hamper the ability to deliver critical care services. Disasters also have the potential to disrupt information technology (IT) in healthcare systems, resulting in interruptions in patient care, particularly critical care, and other healthcare business functions. The suggestions in this chapter are important for all of those involved in a large scale disaster or pandemic with multiple critically ill or injured patients including front line clinicians, hospital administrators, and public health or government officials.

Methodology:  The Business and Continuity of Operations Panel followed the American College of Chest Physicians’ (ACCP) Guidelines Oversight Committee’s methodology in developing key questions regarding medication and supply shortages, and the impact disasters may have on healthcare IT. Task force members met in person to develop the13 key questions felt to be most relevant for Business and Continuity of Operations. A systematic literature review was then performed for relevant articles and documents, reports, and grey literature reported since 2007. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process.

Results:  Eighteen suggestions addressing mitigation strategies for suppy chain vulnerabilities including medications and IT were generated. Suggestions offered to hospitals and health system leadership regarding medication and supply shortages include: 1) purchase of key medications and supplies from more than one supplier, 2) substituted medications or supplies should ideally be similar to those already used by an institution’s providers, 3) inventories should be tracked electronically to monitor medication/supply levels, 4) consider higher inventories of medications and supplies known or projected to be in short supply 5) institute alternate use protocols when a (potential) shortage is identified, and 6) support government and non-governmental organizations in efforts to address supply chain vulnerability. Healthcare IT can be damaged in a disaster, and hospitals and health system leadership should have plans for urgently reestablishing local area networks. Planning should include utilizing portable technology, plans for providing power, maintenance of a patient database that can accompany each patient, and protection of patient privacy. Additionally, long-term planning should include prioritizing servers and memory disk drives, and possibly increasing inventory of critical IT supplies, in preparedness planning.

Conclusions:  The provision of care to critically ill or injured during a disaster or pandemic is dependent on key processes such as the supply chain and infrastructure such as IT systems. Hospitals and health systems will help minimize the impact of medication and supply shortages with a focused strategy using the steps suggested. IT preparedness for maintaining local area networks, functioning clinical information systems, and adequate server and memory storage capacity will greatly enhance preparedness for hospital and health system clinical and business operations.

evidence-based medicine  FREE TO VIEW
Asha V. Devereaux, MD, MPH, FCCP; Pritish K. Tosh, MD; John L. Hick, MD; Dan Hanfling, MD; James Geiling, MD, MPH, FCCP; Mary Jane Reed, MD, FCCP; Timothy M. Uyeki, MD, MPH, MPP; Umair A. Shah, MD, MPH; Daniel B. Fagbuyi, MD; Peter Skippen, MBBS, FRCPC; Jeffrey R. Dichter, MD; Niranjan Kissoon, MBBS; Michael D. Christian, MD, MSc, FRCPC, FCCP; Jeffrey S. Upperman, MD, FAAP, FACS on behalf of the Task Force for Mass Critical Care
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Background:  Engagement and education of Intensive Care Unit (ICU) clinicians in disaster preparedness is fragmented by time constraints, institutional barriers and frequently occurs during a disaster.1 We reviewed the existing literature from 2007 to April 2013 and expert opinions concerning clinician engagement and education for critical care during a disaster or pandemic and offer suggestions for integrating ICU clinicians into planning and response. The suggestions in this chapter are important for all of those involved in a large-scale disaster or pandemic with multiple critically ill or injured patients including front line clinicians, hospital administrators, and public health or government officials.

Methodology:  A systematic literature review was performed and suggestions were formulated according to the American College of Chest Physicians’ Consensus Statement development methodology. We assessed articles, documents, reports, and grey literature reported since 2007. Following expert-informed sorting and review of the literature, key priority areas and questions were developed. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process.

Results:  Twenty-three suggestions were formulated based on literature-informed consensus opinion. These suggestions are grouped according to the following thematic elements: 1. Situational awareness, 2. Clinician roles and responsibilities, 3. Education, and 4. Community engagement. Together these four elements are considered to form the basis for effective ICU clinician engagement for mass critical care.

Conclusions:  The optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a disaster or pandemic will require a departure from the routine independent systems operating in hospitals routinely. An effective response will require robust information systems, coordination between clinicians, hospitals, and governmental organizations, pre-event engagement of relevant stakeholders, and standardized core competencies for the education and training of critical care clinicians.

evidence-based medicine  FREE TO VIEW
Brooke Courtney, JD, MPH; James G. Hodge, Jr., JD, LLM; Eric S. Toner, MD; Beth E. Roxland, JD, M.Bioethics; Matthew S. Penn, JD, MLIS; Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter; MD; Niranjan Kissoon, MBBS; Michael D. Christian, MD, MSc, FRCPC, FCCP; Tia Powell, MD on behalf of the Task Force for Mass Critical Care
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Introduction:  Significant legal challenges arise when health care resources become scarce and population-based approaches to care are implemented during severe disasters and pandemics. Recent emergencies highlight the serious legal, economic, and health impacts that can be associated with responding in austere conditions and the critical importance of comprehensive, collaborative health response system planning. This article discusses legal suggestions developed by the American College of Chest Physicians (ACCP) Task Force for Mass Critical Care (MCC) to support planning and response efforts for mass casualty incidents involving critically ill or injured patients. The suggestions in this chapter are important for all of those involved in a disaster or pandemic with multiple critically ill or injured patients including front line clinicians, hospital administrators and public health or government officials.

Methodology:  Following the ACCP Guidelines Oversight Committee’s methodology, the Legal Panel developed 35 key questions for which specific literature searches were then conducted. The literature in this field is not suitable upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process resulting in seven (7) final suggestions.

Results:  Acceptance is widespread for the health care community’s duty to appropriately plan for and respond to severe disasters and pandemics. Hospitals, public health entities and clincicians have an obligation to develop comprehensive, vetted plans for mass casualty incidents involving critically ill or injured patients. Such plans should address processes for evacuation and limited appeals and reviews of care decisions. To legitimize responses, deter independent actions, and trigger liability protections, MCC plans should be formally activated when facilities and practitioners shift to providing MCC. Adherence to official MCC plans should contribute to protecting hospitals and practitioners, who act in good faith, from liability. Finally, to address anticipated staffing shortages during severe and prolonged disasters and pandemics, governments should develop approaches to formally expand the availability of qualified health care workers, such as through using official foreign medical teams.

Conclusions:  As a fundamental element of health care and public health emergency planning and preparedness, the law underlies critical aspects of disaster and pandemic responses. Effective responses require comprehensive advance planning efforts that include assessments of complex legal issues and authorities. Recent disasters have shown that while law is a critical response tool, it can also be used to hold health care stakeholders that fail to appropriately plan for or respond to disasters and pandemics accountable for resulting patient or staff harm. Claims of liability from harms allegedly suffered during disasters and pandemics cannot be avoided altogether. However, appropriate planning and legal protections can help to facilitate sound, consistent decision-making and support response participation among health care entities and practitioners.

evidence-based medicine  FREE TO VIEW
Lee Daugherty Biddison, MD, MPH; Kenneth A. Berkowitz, MD, FCCP; Brooke Courtney, JD, MPH; Marla J. De Jong, PhD, RN, Colonel; Asha V. Devereaux, MD, MPH, FCCP; Niranjan Kissoon, MBBS; Beth Roxland, JD, MBE; Charles L. Sprung, MD, MCCP; Jeffrey R. Dichter, MD; Michael D. Christian, MD, MSc, FRCPC, FCCP; Tia Powell, MD on behalf of the Task Force for Mass Critical Care
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Background:  Mass critical care (MCC) entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients’ vulnerability and may therefore jeopardize disciplined, ethical decision-making. Planning for disasters and pandemics should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This manuscript provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this chapter are important for all of those involved in any disaster or pandemic with multiple critically ill or injured patients including front line clinicians, hospital administrators, and public health or government officials.

Methodology:  We adapted the American College of Chest Physician’s (ACCP) Guidelines Oversight Committee’s methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions utilizing a modified Delphi process.

Results:  We report the suggestions which focus on five essential domains: triage and allocation; ethical concerns of patients and families, ethical responsibilities to providers; conduct of research; and international concerns.

Conclusions:  Ethics issues permeate virtually all aspects of disaster and pandemic response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation; ethical concerns of patients and families, ethical responsibilities to providers; conduct of research; and international concerns. Our suggestions reflect the consensus of the Task Force. We recognize, however, that some suggestions, including those related to end-of-life care, may be controversial. We highlight the need for additional research and dialogue in articulating values to guide healthcare decisions during disasters.

evidence-based medicine  FREE TO VIEW
James Geiling, MD, MPH, FCCP; Frederick M. Burkle, Jr., MD, MPH; Dennis Amundson, DO, MS, FCCP; Guillermo Dominguez-Cherit, MD; Charles D. Gomersall, BSc, MBBS; Matthew L. Lim, MD; Valerie A. Luyckx, MD; Babak Sarani, MD; Timothy M. Uyeki, MD, MPH, MPP; T. Eoin West, MD, MPH, FCCP; Michael D. Christian, MD, MSc, FRCPC, FCCP; Asha Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Niranjan Kissoon, MBBS on behalf of the Task Force for Mass Critical Care
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Background:  Planning for mass critical care in resource poor or constrained settings (developing or undeveloped countries) has been largely ignored despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing mass critical care in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas.

Methodology:  The Resource Poor Settings panel developed 5 key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidenced-based recommendations, expert-opinion suggestions were developed and consensus was achieved using a modified Delphi process.

Results:  The 5 key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Due to the large number of suggestions the results have been separated into two sections, part I: Infrastructure/Capacity in this manuscript, and part II, Response/Recovery/Research in the accompanying manuscript.

Conclusions:  Lack of, or presence of, rudimentary Intensive Care Unit resources and limited capacity to enhance services further challenge resource poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

evidence-based medicine  FREE TO VIEW
James Geiling, MD, MPH, FCCP; Frederick M. Burkle, Jr., MD, MPH; T. Eoin West, MD, MPH, FCCP; Timothy M. Uyeki, MD, MPH, MPP; Dennis Amundson, DO, MS, FCCP; Guillermo Dominguez-Cherit, MD; Charles D. Gomersall, BSc, MBBS; Matthew L. Lim, MD; Valerie A. Luyckx, MD; Babak Sarani, MD; Michael D. Christian, MD, MSc, FRCPC, FCCP; Asha Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Niranjan Kissoon, MBBS on behalf of the Task Force for Mass Critical Care
Topics: , , , ,

Background:  Planning for mass critical care in resource poor and constrained settings (developing or underdeveloped countries) has been largely ignored despite large densely crowded populations who are prone to suffer disproportionately from natural disasters. As a result, disaster response has been sub-optimal and in many instances hampered by lack of planning, education and training, information, and communication.

Methodology:  The Resource Poor Settings panel developed 5 key question domains; defining the term resource poor, and using the traditional phases of the disaster cycle (mitigation/preparedness/response/recovery) literature searches were conducted to identify evidence to answer the key questions in these areas. Given a lack of data on which to develop evidenced-based recommendations, expert-opinion suggestions were developed and consensus was achieved using a modified Delphi process.

Results:  The 5 key questions were as follows: definition, capacity building and mitigation, what resources can we bring to bear to assist/surge, response, and reconstitution and recovery of host nation critical care capabilities. Addressing these led the panel to offer 33 suggestions. Due to the large number of suggestions the results have been separated into two sections, Part I: Infrastructure/Capacity in the accompanying manuscript, and Part II: Response/Recovery/Research in this manuscript.

Conclusions:  A lack of rudimentary Intensive Care Unit resources and capacity to enhance services plagues resource poor or constrained settings. Capacity building therefore entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is often needed to mount a surge response. Moreover, the disengagement of these responding groups and host country recovery require active planning. Future improvements in all phases require active research activities.

evidence-based medicine  FREE TO VIEW
Sandra Zelman Lewis, PhD; Rebecca L. Diekemper, MPH; Cynthia T. French, PhD, MS, ANP-BC; Philip M. Gold, MD, FCCP; Richard S. Irwin, MD, Master FCCP on behalf of the CHEST Expert Cough Panel
Topics: ,

Background:  This series of guidance documents on Cough, which will be published over time, is a hybrid of two processes: (1) evidence-based guidelines and (2) trustworthy consensus statements based on a robust and transparent process.

Methods:  The CHEST Guidelines Oversight Committee selected a non-conflicted Panel Chair and jointly assembled an international panel of experts in each clinical area with few, if any, conflicts of interest. PICO-based (population, intervention, comparator, outcome) key questions and parameters of eligibility were developed for each clinical topic to inform the comprehensive literature search. Existing guidelines, systematic reviews, and primary studies were assessed for relevance and quality. Data elements were extracted into evidence tables and synthesized to provide summary statistics. These, in turn, are presented to support the evidence-based graded recommendations. A highly structured consensus-based Delphi approach was employed to provide expert advice on all guidance statements. Transparency of process was documented.

Results:  Evidence-based guideline recommendations and consensus-based suggestions were carefully crafted to provide direction to healthcare providers and investigators who treat and/or study patients with cough. Manuscripts and tables summarize the evidence in each clinical area supporting the recommendations and suggestions.

Conclusions:  The resulting guidance statements are based on a rigorous methodology and transparency of process. The recommendations and suggestions provided meet almost all of the guidelines for trustworthiness developed by The Institute of Medicine and can be applied with confidence by physicians, nurses, other healthcare providers, investigators and patients.

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  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543