EMERGENCY MASS CRITICAL CARE

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EMERGENCY MASS CRITICAL CARE

• Lewis Rubinson MD, PhD
• County Health Officer
• Deschutes County Health Department
• Bend, OR
• Medical Officer
• OR-2 DMAT

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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

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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)

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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

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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 ?

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MOST CRITICALLY ILL PEOPLE SURVIVE

• Disaster Situation
• Patients unable to receive mechanical ventilation
  and/or hemodynamic support are likely to die.

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What to do when the number of critically ill
patients far exceeds traditional hospital
critical care capacity and evacuation is not
immediately available?
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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.

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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

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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
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Which critical care interventions should be
provided if resources are limited and usual
critical care cannot be provided to all in need?
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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

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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

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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

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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
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STRATEGIC NATIONAL STOCKPILE VENTILATORS

• Thousands of ventilators
• Not enough for serious pandemic
• Prioritization for distribution to many hospitals
  in need remains uncertain
• NO OXYGEN !

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PPV OPTIONS
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(No Transcript)
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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

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Who should provide Emergency Mass Critical Care?
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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

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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.

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TIERED STAFFINGCritical care staff
collaborating with non-critical care staff on all
patients
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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

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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

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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

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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)

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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
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Triage and Rationing Who should receive
Emergency Mass Critical Care?
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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.
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Where should Emergency Mass Critical Care be
delivered when all usual critical care options
are full?
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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

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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.

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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)

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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
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AVIAN INFLUENZA HITS FLORIDA