Critical Care in Public Health Emergencies

Chapter 18 Critical Care in Public Health Emergencies



Robert K. Kanter



Pearls



• All-hazard, as well as incident-specific, planning and preparedness for public health emergencies make a difference in patient outcomes.

• The Hospital Emergency Incident Command System provides a leadership framework within and among organizations responding to an emergency, emphasizing flexibility and scalability, with clear lines of authority and consistent communications.

• Triage sorts patients to match their needs with available resources and evolves according to shifting needs and resources. Failures of triage may subsequently incapacitate an entire hospital.

• In order to provide essential interventions, some resource-intensive interventions, ordinarily considered standard in an intensive care unit, may have to be delayed or forgone in a mass critical care situation, because standard care would reduce the population who could receive life-saving care.

• If a public health emergency overwhelms resources despite mass critical care approaches, rationing might be considered. However, at present the public and professional consensus that would serve as the necessary foundation for rationing to be a feasible option is lacking.

Recent public health emergencies (PHEs) in North America have included the attacks of September 11, 2001, Hurricane Katrina and the subsequent flooding of New Orleans, a major nightclub fire in Rhode Island, wildfires in the West, floods in the Midwest, anthrax exposures, severe acute respiratory syndrome, and an influenza pandemic. Important lessons have been learned. All-hazard as well as incident-specific planning and preparedness make a difference. When carried out, public health preparations (including evacuation, shelter, and infection control) limited major health effects. Unavoidable illnesses and injuries were often minor, requiring outpatient treatment or first aid for the vast majority of patients. Even when critical care was necessary, existing resources were adequate to provide standard intensive care when needed. However, small differences in circumstances in any of these recent emergencies might have resulted in much larger numbers of adults and children admitted to adult or pediatric intensive care units (ICUs). It is easy to imagine disasters that would overwhelm existing ICU resources, unless we prepare to provide critical care in larger PHEs. This chapter is written for members of the pediatric critical care team facing a major PHE.



Basic Concepts



National Response Framework and Incident Command System


Responses to major public health emergencies are organized within a National Response Framework, as outlined by the federal Department of Homeland Security.1 Emergency responses are always coordinated at the most local jurisdictional level possible, usually at the city or county level. Responses to larger disasters need support from adjacent counties, the state, and sometimes from the federal level. The Hospital Emergency Incident Command System (HEICS)2 provides a leadership framework within and among organizations responding to an emergency. HEICS emphasizes flexibility for any type of event, scalability to the size of the event, clear lines of authority, and consistent communications. Disaster plans at every hospital incorporate HEICS principles.



Ordinary Surge and Mass Critical Care


Critical care responses to PHEs are scaled according to the size and severity of the emergency (Table 18-1).3–5 Responses are categorized as (1) ordinary surge, (2) temporary reactive mass critical care, and (3) sustained mass critical care. For a sudden-impact event involving modest (10% to 15%) increases above usual peak hospital capacity at one or more local hospitals, ordinary surge methods would suffice to provide normal standards of critical care to all those who need it. Ordinary critical care surge needs are met by canceling elective admissions, quickly discharging all patients who can safely leave the ICU, mobilizing staff, and adding beds, as feasible. Most hospitals have occasional experience with ordinary critical care surge responses.


Table 18–1 Categories of Public Health Emergencies and Critical Care Responses



















No. of Patients Type of Event and Response Authority to Implement Response
Modest increase (10%-20%) above usual peak capacity
“Ordinary surge”

Usual standards of care
 Decision making by usual clinical leaders
Up to three times usual peak capacity
Gradual onset, sustained PHE with adequate preparation, resources meet needs, usual standards of care

Sudden-impact PHE, needs exceed resources, temporary “reactive” mass critical care, crisis standards of care

Sustained PHE, sudden or gradual onset, needs exceed resources, sustained mass critical care, crisis standards of care
Decision making by usual clinical leaders

Decision making by hospital incident commander

Decision making by state public health official (varies state by state)4
Exceeds three times usual peak capacity Needs overwhelm resources despite mass critical care, mass critical care, and rationing, crisis and palliative standards of care Legal basis and liability protections are ambiguous38

PHE, Public health emergency.


Data from Devereaux A, Christian MD, Dichter JR, et al: Summary of suggestions from the Task Force for Mass Critical Care, Chest 133:1S-66S, 2008.


Mass critical care approaches would be implemented when a very large PHE threatens to overwhelm critical care resources. It is recommended that mass critical care personnel be able to care for up to three times the usual number of critically ill patients for up to 10 days without outside help. In these circumstances, population-based goals would attempt to maximize numbers of survivors by providing immediate lifesaving interventions to all persons who need them and delaying or forgoing other interventions. Thus standards of mass critical care are not equivalent to normal circumstances and should be considered to be crisis standards of care. Sudden impact events that stress the resources of a community may require the implementation of temporary reactive mass critical care. Experience with a massive surge of critically injured patients after a major fire demonstrated the satisfactory outcomes that are possible as a result of well-organized responses that included elements of the temporary reactive mass critical care approach.6 A sustained PHE that exceeds resources over a wide area may require the sustained implementation of mass critical care. No historical precedents exist for sustained mass critical care.


In many states existing laws would permit mass critical care to be implemented on a temporary reactive basis under the authority of an individual hospital’s incident commander for a sudden impact event that threatens to overwhelm the resources of a hospital. PHE powers are defined on a state-by-state basis.7 Where laws exist to authorize sustained mass critical care, this authority is generally at the level of a state public health official.


Mass critical care, whether temporary or sustained, should guarantee the following lifesaving interventions that can be performed immediately: (1) mechanical ventilation, (2) fluid resuscitation, (3) vasopressors, (4) antidotes and antibiotics, and (5) analgesia and sedation.


Lifesaving mass critical care interventions would be extended to much larger than usual numbers of patients by the following approaches: (1) Substitution of equivalent available interventions for scarce or unavailable treatments; (2) adapting nearly equivalent available interventions instead of other scarce or unavailable treatments; (3) conservation of resources; and (4) reuse of some single-use items. Such modifications from usual practices would be proportional to the gap between needs and resources and would be implemented in an organized way by each hospital’s HEICS.



Pediatric Critical Care Needs and Resources in a Public Health Emergency


If a PHE affected persons of all ages equally, then children aged 0 to 14 years would account for 20% of the patients and children aged 0 to 19 years would account for 28% of the patients.8 Younger patients may be more vulnerable to infections, dehydration, toxins, and trauma and are less able to protect themselves in a dangerous environment. Thus children may be overrepresented in a patient population during a PHE. Accidents involving a child-specific activity or terrorism intentionally targeting children may result in a patient population predominantly made up of children. Some planning scenarios considered by the Department of Homeland Security exceed the entire national critical care capacity.3


Survival rates from high-risk pediatric conditions tend to be better when children receive care at pediatric hospitals.9–12 The younger the patient, the more age-specific are the treatment requirements. A national survey estimated a pediatric ICU (PICU) peak capacity of 54 beds per million pediatric population.13 Because normal PICU occupancy exceeds 50%, fewer than 30 vacant PICU beds per million age-specific population are generally available in a region. Because each region may only be served by a single or a few pediatric hospitals, events that disable a pediatric hospital may disproportionately degrade regional pediatric care.


Quantitative models indicate that survival in a PHE would be better if pediatric patient surge is distributed to pediatric beds throughout a region, rather than overloading facilities near the scene of an emergency.14 Appropriate utilization of pediatric hospitals would be promoted by clear identification of pediatric hospitals.15,16 Unfortunately, control of patient distribution may be impossible in a PHE.17 As a result, all hospitals must be prepared to care for some children.18 Even if pediatric regional resources are used optimally, hospital vacancies to accommodate pediatric surges are empirically much more limited than for adult patients.19 Whether or not patients are distributed optimally to hospitals, outcomes from a hypothetical large PHE are likely to be better with mass critical care approaches.14,20



When the PICU Is Notified of a Sudden-Impact Public Health Emergency


When a sudden-impact PHE is announced, PICU clinical leaders must immediately focus attention on safety of patients and staff. The hospital’s HEICS is activated. Normal operations continue until other instructions are received. Staff who are already in the hospital report to their normal assigned work area, notifying their supervisor of their arrival. PICU clinical leaders review the hospital disaster plan, including job action sheets, and discuss pertinent aspects with the staff. When possible, the PICU clinical leaders will be informed about type, number, and arrival time of anticipated patients. However, such information is often unavailable and inaccurate. Scheduled admissions are reviewed for potential cancellation. Patients in the PICU are evaluated for transfer to a lower level of care or discharge.


Based on the initial assessment, ICU leaders need to determine the number of additional patients who could be accommodated with available staff, equipment, supplies, and space to provide normal standards of care. Additional needs for staff, equipment, and supplies should be communicated through appropriate channels in the HEICS. Additional staff is called in when HEICS instructs the staff present to do so. Staff already in the hospital may be reassigned by HEICS. Staff responding from outside should report to a labor pool area for assignment. Areas designated for expansion of services and overflow are prepared when instructed by HEICS.


As information about the event becomes available, PICU physician and nurse leaders provide incident-specific just-in-time teaching to staff when warranted. Just-in-time teaching is especially important when less experienced supplemental providers are assigned to the PICU.


Rapidly accommodating patients from the emergency department (ED) or operating room will be essential in allowing those areas to continue receiving new patients. At all times, clinical leaders must maintain awareness of the environment, operational problems, disaster-related communications, and reactions of staff, patients, and families.



Emergency Department Phase


To provide continuity in patient care, the PICU team must interact closely with the ED. In some cases, PICU staff may be temporarily reassigned to work in the ED. Therefore, the critical care team should be familiar with the ED perspective on disaster responses.



Triage


Triage sorts patients to match their needs with available resources. Triage is an evolving process relative to shifting needs and resources. Prehospital field triage and care is beyond the scope of this chapter, but when it is effective, patients are selected who will benefit from ED care. Some mild patients not requiring ED care may have been overtriaged, and others may arrive at the ED without prehospital assessment. The worried may well constitute a large proportion of patients arriving at an ED. Severely ill or injured patients may arrive later than those with less serious conditions in a sudden impact emergency. Triage categories are assigned in the ED by an experienced clinician whose sole role is to act as triage officer. Elements of the triage process may have to be repeated later according to evolving imbalances of patient needs and resources.


Triage at the ED is performed according to the nature of the PHE. When potential contamination of victims by toxins is involved, initial triage outside the hospital first identifies those needing immediate decontamination to protect the patient, staff, and entire hospital facility. Likewise, when a highly transmissible virulent infection is involved, triage prior to entering the ED identifies and isolates potentially infectious patients at the earliest time to avoid exposing staff and other patients. Failures of triage at the early stages of decontamination and infection control may subsequently incapacitate an entire hospital. When pertinent, the patient’s medical record should clearly indicate decontamination procedures done and the patient’s infection control status.


Physiologic triage identifies patients needing immediate lifesaving interventions. Physiological triage tools identify patients in five categories: (1) those needing immediate lifesaving interventions; (2) those who need significant intervention that can be delayed; (3) those needing little or no treatment: (4) those who are so severely ill or injured that survival is unlikely despite major interventions; and (5) those who have already died. Care of patients triaged to group 4, those who are so severely ill or injured that survival is unlikely, must deviate most significantly from usual approaches to intensive care. Because of overall demands on the system, scarce resources must be allocated to other patients who are more likely to survive. Group 4 patients are sometimes referred to as “expectant.” Expectant patients are defined by current resource constraints as well as physiological observations. Palliative care is always provided to expectant patients. Also see the discussion of rationing at the end of this chapter.


It is beyond the scope of this chapter to advocate one triage tool in preference to others. No single tool is always rapid, completely accurate, appropriate to all ages and disorders, and already familiar to all providers.21 Staff should be familiar with the physiological triage tool in use locally.

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