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EMERGENCY MASS CRITICAL CARE

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Title: EMERGENCY MASS CRITICAL CARE


1
EMERGENCY MASS CRITICAL CARE
  • Lewis Rubinson MD, PhD
  • County Health Officer
  • Deschutes County Health Department
  • Bend, OR
  • Medical Officer
  • OR-2 DMAT

2
HUMAN CASES H5N12004-2006
  • Case fatality rate 50
  • Most deaths from refractory respiratory failure
  • Most people are critically ill
  • Respiratory failure gt 70
  • Shock
  • Acute renal failure 10-29
  • In US, pts with similar severity of illness are
    managed in ICUs

3
CRITICAL CARE DEMAND
  • Number of critically ill patients
  • ?? availability and effectiveness of
    countermeasures
  • Uncertain virulence of strain if human-to-human
    transmission
  • Rate of development of critical illness
  • Time from hosp to resp failure lt 2 days
  • Duration of critical illness
  • Time from hosp to death 4-30 days (most
    cohorts median gt 1 week)

4
LIMITED ICU SURGE CAPACITY
  • 87,400 ICU beds in non-federal US hospitals
  • ICU occupancy 65-80
  • Breadth of ICU meds and equipment create
    financial barriers to building reserve ICUs
  • Logistical difficulties of using reserve ICU and
    need for equipment maintenance further barriers
  • Shortages of critical care nurses, pharmacists,
    respiratory therapists and intensivists in most
    communities
  • gt 10 of ICUs have beds closed due to nursing
    shortage

5
ADDITIONAL PANDEMIC CRITICAL CARE CHALLENGES
  • Concurrent impact on many hospitals
  • Limited evacuation
  • Limited deployment of stuff and staff
  • Infection control measures increase critical care
    challenges
  • Prolonged response
  • Fatigue
  • How long can cancel elective surgeries, use
    anesthesia machines, repurpose staff ?

6
MOST CRITICALLY ILL PEOPLE SURVIVE
  • Disaster Situation
  • Patients unable to receive mechanical ventilation
    and/or hemodynamic support are likely to die.

7
What to do when the number of critically ill
patients far exceeds traditional hospital
critical care capacity and evacuation is not
immediately available?
8
OPTIONS
  • Provide usual ICU services on a first-come
    first-served basis.
  • Stop providing critical care services.
  • Plan and prepare for usual ICU services for all
    additional patients.
  • Modify standards of critical care to provide
    limited but high-yield critical care
    interventions and processes for many additional
    patients.

9
EMERGENCY MASS CRITICAL CARE
  • Emergency changes in
  • Spectrum of critical care interventions
  • Triage
  • Staffing
  • Medical equipment
  • Clinical trials
  • Provide circumscribed set of key critical care
    interventions to many patients rather than
    maximal critical care to far fewer
  • Derived from recommendations of a working group
    of 33 North American experts

10
WORKING GROUP ON EMERGENCY MASS CRITICAL CARE
Critical Care Edward Abraham, MD Richard Branson,
RRT, MS Kathryn Brush, RN, MS James Cushman, MD J
Christopher Farmer, MD Mitchell Fink, MD Leonard
Hudson, MD Stephen Lapinsky, MB, MSc Margaret
Parker, MD Thomas Stewart, MD Daniel Talmor, MD,
MPH Infection Control/ ID John Bartlett,
MD Allison McGeer, MD Andrew Streifel, MPH
Biosecurity Luciana Borio, MD D A Henderson, MD,
MPH Thomas Inglesby, MD Jennifer Nuzzo, SM Tara
O Toole, MD, MPH Lewis Rubinson, MD, PhD Local
Public Health Katherine Uraneck, MD DHHS Andrea
Argabrite, FNP MS Steven Bice Robert Claypool,
MD Sally Phillips RN, PhD Matthew Tarosky, Pharm-D
Bioethics Nancy Dubler, LLB Ruth Faden,
PhD Disaster Medicine Michael Allswede, DO Dan
Hanfling, MD Kevin Yeskey, MD Hospital
Admin. Mark Ackermann Richard Waldhorn, MD
11
Which critical care interventions should be
provided if resources are limited and usual
critical care cannot be provided to all in need?
12
FREQUENTLY USED ICU INTERVENTIONS
  • Intra-aortic counter-pulsation device
  • Continuous renal replacement therapy
  • ICP monitoring
  • High-frequency oscillatory ventilation
  • Activated protein C infusion
  • Conventional mechanical ventilation
  • Vasopressor infusion
  • Large volume blood product transfusions
  • Intra-arterial blood pressure monitoring

13
PRIORITIZING CRITICAL CARE INTERVENTIONS
  • Supports the organ systems most likely to cause
    death
  • Demonstrated effectiveness or best professional
    judgment to improve survival in similar clinical
    conditions
  • Do not require prohibitively expensive equipment
  • Not staff or resource intensive

14
EMERGENCY MASS CRITICAL CARE INTERVENTIONS
  • Mechanical ventilation
  • Basic mode(s)
  • Hemodynamic support
  • IV fluids, vasopressor(s)
  • Set of prophylactic interventions
  • Thromboembolism prophylaxis, elevation of head of
    bed and ? GI prophylaxis

15
AUGMENTING POSITIVE PRESSURE VENTILATION (PPV)
  • Reserve sophisticated full-feature ventilators
  • Vendor rental supply
  • Limited data regarding quantities available,
    especially during large event with many
    requesting hospitals
  • Anesthesia machines
  • Adequate short-term option, but limited
    quantities and cannot be repurposed for long
    response
  • Alternative ventilation options

Increasing numbers of victims needing PPV and
evacuation not immediately possible
16
STRATEGIC NATIONAL STOCKPILE VENTILATORS
  • Thousands of ventilators
  • Not enough for serious pandemic
  • Prioritization for distribution to many hospitals
    in need remains uncertain
  • NO OXYGEN !

17
PPV OPTIONS
18
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19
PPV MAY STILL BE LIMITED
  • Non-federal PPV caches will increase equipment
    capacity BUT for severe pandemic capacity is
    still likely to be exceeded by demand.
  • ? Attack rate
  • ? Virulence
  • ? Concurrent PPV demand
  • ? Geographical impact

20
Who should provide Emergency Mass Critical Care?
21
USUAL ICU STAFFING
  • Ideal ICU staffing
  • Critical care pharmacists, respiratory
    therapists, nurses, registered dietitians and
    intensivists
  • Low NursePatient ratios associated with worse
    outcomes
  • Pharmacists participation on daily rounds reduce
    adverse drug events
  • Respiratory therapists are invaluable for
    maintenance and operation of airway and
    ventilation equipment

22
STAFFING FOR EMERGENCY MASS CRITICAL CARE
  • May have a number of non-critical care staff
    available
  • Surgeons, anesthesiologists if elective surgeries
    cancelled
  • Non-critical care allied health professionals
  • --HOWEVER--
  • Complexities of critical care may limit
    effectiveness of non-critical care staff working
    independently.

23
TIERED STAFFINGCritical care staff
collaborating with non-critical care staff on all
patients
24
TIERED NURSING
  • Non-critical care nurses assigned primary
    responsibility for patient assessment
  • Documentation
  • Administration of medications
  • Bedside care (maintaining head of bed at 45,
    moving pts to prevent pressure ulcers)
  • Real-time patient assessment

25
TIERED NURSING
  • Critical care nurses can supervise and advise
    non-critical care nurses on critical
    care-specific issues
  • Vasopressor and sedation titration
  • Suggested ratio (depending on situation)
  • 1 non-critical care nurse to 2 pts 3
    non-critical care nurses collaborating with 1
    critical care nurse

26
TIERED NPs, PAs,MDs,DOs
  • Non-intensivists responsible for general care of
    patients.
  • Initial response to changes in patients
    condition
  • Documentation of care and care plan
  • Most non-critical care medical issues
  • Critical care issues after consultation with
    intensivist or implementing standardized order
    sets
  • Intensivists manage acute emergencies,
    ventilator-patient interaction (together with
    RTs), and consult on general critical care issues

27
TIERED NPs, PAs,MDs,DOs
  • 1 non-intensivist to 6 patients 4
    non-intensivists to 1 intensivist
  • Non-intensivists should receive basic critical
    care training as part of disaster preparedness
    (e.g. HDM)
  • Standardized order sets
  • Reduce variability and errors of omission
  • Modify for specific disease (e.g. pandemic
    influenza, inhalational anthrax)

28
STAFFING COMPARISON
Assumes 12 patients, 24 hour period. Assumes 12
nursepatient ratio, 12 hour shifts, and one
charge nurse per shift without a patient-care
assignment. Assumes 24-hour intensivist coverage
29
Triage and Rationing Who should receive
Emergency Mass Critical Care?
30
TRIAGE OPTIONS DURING OUTBREAKS
  • First-come, first-served
  • Current critical care triage
  • Prioritization based on likelihood to benefit
  • Utilitarian the greatest good for the greatest
    number
  • Prioritization based on social worth

Pesik N, et al. Annals of Emerg Med. 2001.
31
Where should Emergency Mass Critical Care be
delivered when all usual critical care options
are full?
32
EMERGENCY MASS CRITICAL CARE IN HOSPITALS
  • PACU, ED provide only a handful of additional
    beds
  • Equipment, medical gases, isolation, and using
    tiered staff most safely and efficiently provided
    on concentrated hospital wards
  • Step-down units first, then general hospital
    wards
  • If prolonged disaster repurposing endoscopy, cath
    labs, and ORs less optimal
  • Non-hospital alternate care sites should be used
    for non-critically ill patients

33
EMERGENCY MASS CRITICAL CARE BEDS
  • ICUs usually 5-15 of total inpatient beds
  • In past, hospitals have made approximately 20
    inpatient beds available within 24 hours by
    recalling staff, canceling surgeries, expedited
    discharges
  • Can increase hospital total critical care
    capacity by 2-4 fold if critically ill patients
    given admission priority
  • As outbreak unfolds, can likely increase critical
    care capacity 5-10 fold over existing ICU
    capacity.

34
EQUIPMENT FOR EMERGENCY MASS CRITICAL CARE
  • Portable ventilators, anesthesia machines and/or
    full-feature ventilators
  • Medical gas, suction
  • Pulse oximeter
  • Non-invasive blood pressure cuffs
  • Urine quantification device
  • IV administration equipment (hospitals may choose
    to have central venous catheters)

35
EMERGENCY MASS CRITICAL CARE
  • Emergency Changes
  • Scope of critical care
  • Critical care triage
  • Staffing
  • Equipment
  • Clinical Trials
  • Assumptions
  • Some critical care is better than no critical
    care
  • Knowledge about usual critical care interventions
    can guide prioritization of high yield
    interventions

Goal provide the best possible outcomes for
the greatest number of patients
36
AVIAN INFLUENZA HITS FLORIDA
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