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Disaster planning: A comprehensive approach
A recently published report outlines critical care response during the most trying of times.
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A truly comprehensive approach to disaster planning in U.S. hospitals was published in a supplement to Chest, the journal of the American College of Chest Physicians in May 2008. It is available online for anyone who is interested in examining their recommendations in detail. It was prepared by a 37-member Task Force for Mass Critical Care and included not only experts in critical care but also emergency medicine, bioethics, law, and nursing, as well as local, state and federal emergency planners.
Admittedly, this is not a bread and butter issue for infectious disease physicians. We certainly do, however, have a vested interest in some aspects of it, as the most probable infectious disease disaster will be either a bioterrorism event or severe 1918-scope pandemic influenza. It is impossible to even hazard a guess as to which of those events may be more likely. In any event, it certainly behooves us as ID physicians to be aware of these kinds of plans and to support them should the opportunity arise.
There are four individual reports in the supplement, as well as a summary and an accompanying editorial, the latter published not in the supplement but in the May 2008 issue of Chest. They all deal with providing definitive care for the critically ill during a disaster. Communities are recommended to develop graded response plans that clearly indicate what levels of modification of existing critical care facilities may be needed. Hence a number of tiers of response are outlined, ranging from simple multiple vehicle accidents to overwhelming local, regional, statewide or even national disasters.
The first article describes the current capabilities and limitations of care for those critically injured during a disaster in the United States. It deals with “stuff, staff, and space” and actually sets the scene for the development of the remaining three reports. The second report outlines a framework for optimizing critical care surge capacity, using an approach referred to as “emergency mass critical care” (EMCC). This would require ICUs to essentially shift gears and devote all resources to mass critical care rather than the traditional unrestricted critical care to which we have grown accustomed. Furthermore, hospitals are asked to plan for three times the usual ICU capacity, and to be able to continue using the EMCC approach for up to 10 days! This will, of course, represent a huge challenge for hospitals and hospital planners. Moving to EMCC would be necessary only at the very highest tiers of response. The third report outlines the medical resources needed to accomplish EMCC, again in terms of stuff, staff and space.
Distributing resources
The fourth report describes a framework for allocation of limited resources in mass critical care. This is the report that has drawn the most media attention, and for obvious reasons, for it deals with rationing — not of care, but rationing of potentially life-saving care when demand exhausts the medical system and not all can receive critical care. The paradigm necessarily has to shift here from the individual to the population. This is a relatively easy transition for an epidemiologist but much more difficult for the clinician whose primary focus is always the patient at hand.
Critically-injured patients would be graded by daily Sequential Organ Failure Scores (SOFA) and chronic illness severity.
If the likelihood of in-hospital mortality is 80% or greater, they would be excluded from receiving critical care and would be given what basically amounts to comfort and supportive care. Among life-limiting illnesses that could exclude patients from receiving critical care resources are: severe trauma, severe burns, cardiac arrest that does not respond to electrical therapy, severe baseline cognitive impairment, metastatic malignancy, advanced and irreversible neurological disease, end-stage organ failure and age older than 85 years.
The “triage officer” under such conditions of limited resources thus must make decisions about what will benefit the largest number of patients, even though such decisions may not necessarily be in the best interest of any specific individual patient. In a society such as ours, it is critically important that such decision-making receive some kind of a priori legal “blessing” and that such decision-making be utterly transparent.
Realistically, this may not always be possible. If such decision-making is undertaken without those two elements in place, however, expect wrongful death suits to clog the courts for years.
I have necessarily not been able to touch on many key aspects of the Task Force Report, including particularly details of gearing up to be able to provide emergency mass critical care, if necessary to do so, and details of the kinds of problems to be encountered in considering resources of staff, space and equipment and possible “work-arounds.” Obvious examples of anticipated equipment shortages are ventilators, medical gases, especially high-pressure oxygen and garden-variety medical supplies that fail to arrive because of interrupted transportation/delivery systems. Some critical care space can easily be increased by converting pre- and post-anesthesia care units for ICU use.
Regarding staffing, using non- critical care staff in critical-care units may be fraught with risk, but using such staff for noncritical care duties, eg, medication administration, may help alleviate shortages.
Again, interested readers are urged to read the entire supplement. The report is comprehensive, carefully reasoned, and although it is not pleasant reading, it behooves us to be familiar with it and to support it to the extent possible. Will individual hospitals and hospital groups climb on board? Probably not, unless shaken out of our prevailing attitude of complacency.
Recent events such as Hurricane Katrina, the recent cyclone in Myanmar and the massive earthquake in China may seem remote but could happen again here – tomorrow.