|
| ||||||||
| ||||||||
|
Biosecurity BriefingTask Force Provides Guidance for Managing Mass Critical Care during a Disaster By Brooke Courtney, May 9, 2008 In a supplement to the May 2008 issue of the journal Chest, four articles offer guidance for hospitals, health professionals, and public health officials on providing mass critical care during a disaster.1 The documents were drafted by the Task Force for Mass Critical Care, which was convened in 2007 and is composed of 37 experts from various fields, such as bioethics, critical care, emergency medicine, infectious diseases, law, nursing, and government planning and response, including the U.S. Department of Health and Human Services.1 According to the Task Force, “pre-event planning can help avoid crisis decision making” and a “[s]uccessful response to such overwhelming situations depends largely on having an effective conceptual and operational framework” in place.1 To that end, the Task Force proposes an emergency mass critical care (EMCC) framework, but notes that use of such frameworks “should be restricted to overwhelming mass critical care events” when there are “extreme mismatches between patient need and available resources.”2 The Task Force documents are “intended to aid clinicians and disaster planners in providing a coordinated and uniform response to mass critical care…to do the greatest good for the greatest number.”1 However, the Task Force concedes that their recommendations are to serve as a “beginning in this planning process...as hospitals practice, drill, and achieve surge capacity, the suggestions will require modification.”1 Following is a brief summary of each article: Document 1, Current Capabilities and Limitations, provides a review of U.S. and Canadian mass critical care disaster response capabilities and the rationale and context for the majority of the suggestions outlined in the other three documents.1,3 Document 2, A Framework for Optimizing Critical Care Surge Capacity, offers a set of critical care therapeutics and interventions for responding to mass critical illness, benchmarks for surge capacity, the EMCC framework for modified care, and criteria—or tiers—for when essential critical care should be used.2 For example, every hospital with an intensive care unit (ICU) should plan, in coordination with regional hospital efforts, to deliver EMCC for at least triple their usual ICU capacity for ten days without sufficient external assistance.2 Document 3, Medical Resources for Surge Capacity, outlines “medical equipment, concepts to expand treatment spaces, and staffing models for EMCC” based on clinical practice guidelines, medical resource utilization data, and, if needed, expert opinion.4 For example, “EMCC requires one mechanical ventilator per patient concurrently receiving sustained ventilatory support.”4 Document 4, A Framework for Allocation of Scarce Resources in Mass Critical Care, “provides guidance for standardized and fair means to distribute scarce critical care resources.”1,5 Specifically, rationing of critical care should occur only after all augmentation efforts have been exceeded.5 The triage process during the allocation of scarce resources should be implemented and coordinated by a triage officer and support team and is designed to be objective, adaptable to resource supply and demand, and consider disease- or event-specific circumstances.5 In addition, the process is composed of inclusion criteria, exclusion criteria, and prioritization of care.5 For example, to be admitted to critical care, “patients must require active critical care interventions,” such as mechanical ventilation.5 If patients meet exclusionary criteria (e.g., severe trauma with a short life expectancy, end-stage organ failure meeting certain criteria, or age >85 years), critical care resources may be reallocated to other patients, but patients ineligible for critical care will continue to receive supportive medical or palliative care.5 After applying the inclusion and exclusion criteria, patients should be prioritized from least sick to most severely ill using certain daily scores, trends, and clinical factors.5 As reported in Science Daily, the framework represents a “major step forward to uniformly deliver sufficient critical care during catastrophes and maximize the number of victims who have access to potential life-saving interventions.” Task Force member Asha Devereaux stated that "Most countries, including the United States, have insufficient critical care resources to provide timely, usual care for a surge of critically ill and injured victims. If a mass casualty critical care event occurred tomorrow, many people with clinical conditions that are survivable under usual health-care system circumstances may have to forgo life-sustaining interventions due to deficiencies in supply, staffing, or space."6 Another Task Force member, Lewis Rubinson, reported that it is ideal if hospitals have an emergency mass critical care plan in place that would prevent them “from needing to ration critical care resources.” However, in the event that surge capacity is exceeded beyond those plans, “the use of emergency mass critical care triage and rationing will help local health-care facilities [to] minimize mortality and optimize survival.”6 References
|