Pandemic Influenza Preparedness Planning

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Pandemic Influenza Preparedness Planning

• Ventilator Triage Protocol
• ASTHO Senior Deputies Meeting
• July 9, 2008
• Elkhart Lake, Wisconsin
• Gus Birkhead, MD, MPH
• New York State Department of Health

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Source MMWR 199948621-29
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Influenza Pandemics20th Century
Credit US National Museum of Health and Medicine
1918 Spanish Flu
1957 Asian Flu
1968 Hong Kong Flu
A(H2N2)
A(H1N1)
A(H3N2)
50-100 m deaths675,000 US deaths
1-4 m deaths70,000 US deaths
1-4 m deaths34,000 US deaths
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Potential Impact of a Category 5 Pandemic
Influenza on NYS

• Severe (1918-like) pandemic, New York State can
  expect, over 6 weeks
• 6.75 million people become ill (35 of the
  population)
• 771,000 flu hospital admissions (3-fold
  increase )
• Peak week approx 800 of ICU bed capacity
  (3600)
• Peak week approx 400 of ventilator capacity
  (3700)
• Six week flu deaths 153,000
• vs. 1400 flu deaths in an average season
• vs. 17,500 total deaths in an average 6 week
  period

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Goal of Pandemic Flu Response
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Pan Flu Planning AccomplishmentsState Health
Department

• Develops and updates the Pandemic Influenza Annex
  to the States All Hazards plan. Lead response
  with SEMO.
• http//www.nyhealth.gov/diseases/communicable/infl
  uenza/pandemic
• Since 2003 16 statewide, multi agency table tops
  and 18 full scale preparedness exercises
• Conducts human disease surveillance and lab
  testing.
• Coordinates health care system response EMS
  services
• Maintains statewide electronic systems to issue
  health alerts and track health system resources
• Maintains Medical Emergency Response Cache (MERC)
  
• 1 million antiviral treatment courses, 4 million
  surgical masks, 500,000 N95 masks, 850
  ventilators, other medical supplies.
• Administers federal public health/hospital
  preparedness grants liaison with federal
  emergency medical stockpile

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Ventilator Shortage in a Pandemic

• Different estimates of severity based on CDC
  calculations
• Federal ventilator stockpile
• NYS ventilator stockpile
• Most severe epidemic
• Too few ventilators for patients
• Too few staff for more ventilators
• Rationing of ventilators needed

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Disaster Med Public Health Preparedness.
200822026
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Rationing Ethical Implications

• Limits patient autonomy
• Limits physician autonomy
• Could shift doctors obligation from patient to
  group
• Radical threat to doctor- patient relationship
• Ethical principles
• Duty to Care
• Duty to Steward Resources
• Duty to Plan
• Transparency
• Justice

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Clinical Algorithm

• Applies to all acute care patients, not just
  influenza patients
• No special treatment for any groups (e.g. HCWs,
  1st resp.)
• Only triggered when need overwhelms supply
• Ventilator access based on patients score,
  objective criteria,
• NOT based on comparison to next patient
• Clinical criteria Exclusion criteria SOFA
  score
• Objective, clear, easily measured criteria
• Rule-in severe respiratory compromise
• Rule-out end-stage illness
• Ventilator treatment for timed period with
  periodic review
• Initial, 48 hours, 120 hours

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Disaster Med Public Health Preparedness.
200822026
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SOFA Scoring

• SOFA criteria (Sepsis-related Organ Failure
  scale)
• Non-proprietary
• Simple, reproducible
• Evidentiary basis for estimating mortality
• Points added based on objective measures of
  function in six key organs and systems lungs,
  liver, brain, kidneys, blood clotting, and blood
  pressure
• Range from 0 -24
• 0 is the best possible score 24 is the worst
• Milestone Scores
• 11 denied access

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SOFA Scoring System
Adapted From Ferreira Fl, Bota DP, Bross A,
Melot C, Vincent JL. Serial evaluation of the
SOFA score to predict outcome in critically ill
patients. JAMA 2001 286(14) 1754-1758.
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Disaster Med Public Health Preparedness.
200822026
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Triage Decision-making

• Time trials, objective clinical criteria
• Primary clinicians care for patients
• Triage decisions made by triage officers
• Role sequestration for decision-makers,
  clinicians
• Palliative care
• Triage, not abandonment
• Policies for end-of-life care
• Continue non-ventilator treatments
• Liability

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Review of Triage Decisions

• Option 1 Appeals process
• Separate team from triage
• Case by case prospective review
• Decision delayed during appeal
• Option 2
• Daily review of triage decisions
• Maintains consistency, fairness
• Permits monitoring of number, type of triage
• decisions

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Ventilator Triage Public Comment

• NYSDOH email PanFlu_at_health.state.ny.us
• Websites www.nyhealth.gov

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New York State Workgroup on Ventilator Allocation
in an Influenza Pandemic

• Co-Chairs Guthrie S. Birkhead, MD Tia Powell,
  MD
• New York State Department of Health
  Representatives Barbara Asheld, JD Mary Ann
  Buckley, RN, MA, JD Bob Burhans Bruce Fage
  Mary Ellen Hennessy, RN Marilyn Kacic John
  Morley, MD Loretta Santilli Perry Smith
  Barbara Wallace, MD, MSPH Dennis Whalen Lisa
  Wickens, RN Vicki Zeldin, MS
• New York State Task Force on Life and the Law
  Staff Michael Klein, JD Kelly Christ, MHS
• Outside Experts Ron Bayer, PhD, Mailman School
  of Public Health Columbia University Kenneth
  Berkowitz, MD, FCCP, New York University School
  of Medicine Kathleen Boozang, JD, LLM, Seton
  Hall University School of Law David Chong, MD,
  New York University School of Medicine Brian
  Currie, MD, Montefiore Medical Center Nancy
  Dubler, LLB, Montefiore Medical Center Paul
  Edelson, MD, Mailman School of Public Health,
  Columbia University Joan Facelle, MD, Rockland
  County Department of Health Joseph J. Fins, MD,
  New York Presbyterian Hospital-Weill Cornell
  Center Alan Fleischman, MD, New York Academy of
  Medicine Lewis Goldfrank, MD, New York
  University School of Medicine Patricia Hyland,
  MEd, RRT, RT, Hudson Valley Community College
  Marci Layton, MD, New York City Department of
  Health and Mental Hygiene Kathryn Meyer, JD,
  Continuum Health Partners Inc Tom Murray, PhD,
  The Hastings Center Margaret Parker, MD, FCCM,
  State University of New York-Stony Brook Lewis
  Rubinson, MD, Centers for Disease Control and
  Prevention Neil Schluger, MD, Columbia
  University College of Physicians and Surgeons
  Christopher Smith, Healthcare Association of New
  York State Kate Uraneck, MD, New York City
  Department of Health and Mental Hygiene Susan
  Waltman, JD, MSW, Greater New York Hospital
  Association.

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